INTRODUCTION
I first met Serena when I did my clinical placement in the Psychiatry of Old Age (POA) department in Eccles Street over a year ago where she attended as an out-patient once weekly. My preceptor and I have both agreed that Serena would be a suitable client for me to work with as we feel that knowing her from a previous work experience have provided me with an advantage to easily establish an effective therapeutic relationship with her. Also, Serena’s required interventions are within the scope of practice of a Level 3 student nurse under the An Bord Altranais guidelines.

Serena is an 82-year old woman who lives in her north inner city Dublin home with her husband Dan. They have four sons who now have families of their own but are all supportive and are still very much present in their lives. Her only sister, Blair, lives in a nearby county but visits her twice a week. Her relationship with her family is identified as her main support system.

Serena is known to the psychiatric services due to her long history of Bipolar Affective Disorder and previous suicide attempts, resulting to numerous psychiatric admissions. She was on lithium for approximately 18 years, which now resulted for her thyroid to become toxic and her kidneys to completely stop functioning. She has been recently diagnosed of End Stage Renal Failure (ESRF). This recent diagnosis has left her more anxious and depressed. As her family and the Community Mental Health Team (CMHT) from the POA unit had worrying concerns regarding her increasing inability to cope at home and recent suicide attempt, they have decided to refer her to Golden Living Centre (GLC) for respite. GLC is a nursing home where I did my 8-week specialist placement.

The CMHT from the POA unit visits Serena on a weekly basis ensuring continuity of care. The community mental health nurse (CMHN) comes in to the nursing home once a week to gather feedback from the nursing staff regarding Serena’s current mental state. The CMHN also talks to Serena providing one-on-one support. The CMHN then reports all the gathered information back to the consultant psychiatrist and the said psychiatrist comes in to the nursing home to talk to Serena and to evaluate her thoughts, feelings, perceptions, and any developments made. Serena’s relationship with her CMHT is also considered as one of her support systems.

The main health concern for the CMHT and the nursing staff from the nursing home was the risk of suicide Serena posed and thus, becoming the priority of her care. She took an overdose a few months before her admission to the nursing home. “I feel no hope, like I’ve nothing to look forward to,” as she would justify her action. This attempt to end her life was the very reason why she was referred to the said long-term care facility. The other health concern that needs to be addressed was Serena’s presentation of a more depressed state leading to her ineffective coping behaviour. Serena attends the dialysis clinic in the Mater Hospital three days per week and being on dialysis has put her on a great amount of stress. “This shouldn’t happen to a lady of my age, I’m not fit for it,” she would often complain. Serena reported that after her ESRF diagnosis, she’d find it difficult to get an 8-hour sleep. Her husband would also report that while at home on a weekend pass, he’d notice her not eating, feeling really low and showing no interest with doing any of the activities she used to enjoy doing. Nursing staff from GLC have also noticed episodes of agitation, becoming easily upset when demands are not met.

ASSESSMENT
Videbeck (2009) explains that an assessment is an ongoing, tentative and transparent process undertaken with the support of documentation wherein the nurse engages collaboratively and therapeutically with the client to develop an agreed plan of care. GLC developed Serena’s care plan and all of the other residents in a way that their mental health needs are appropriately addressed to as well as effectively managing their physical illness at the same time. The CMHT focuses primarily on Serena’s psychosocial needs, while the nursing staff of GLC responds to both her psychosocial and physical needs but primarily focuses on her physical status and reports of pain or discomfort.

According to Cutcliffe (2003), some people suffering from a mental disorder may be at risk of committing suicide or otherwise seriously harming themselves hence, the need for a clinical risk assessment. Clinical risk assessment is an established tenet of psychiatric treatment concerned with the nature of risk and the types of harm that might occur which in turn, threatens an individual’s health as well as life (Gamble and Brennan 2003).

Barker (1997) suggested that much of the data that is needed to gage the probability of a person committing suicide can be obtained from interviews only, but a combination of scales and interviews enhances suicide risk assessments. I used the SAD PERSONS Scale to determine Serena’s probability of attempting to commit suicide. The scale is used to evaluate suicide potential based on ten major suicide risk factors: Sex, Age, Depression, Previous Attempt, Ethanol Abuse, Rational Thinking Loss, Social Supports Lacking, Organised Plan, No Spouse, and Sickness (Zastrow and Kirst-Ashman 2010). Serena got a total score of four in the scale indicating a moderate risk of suicide potential and requiring close follow-up (See Appendix).

Another tool that is employed in the GLC care plans is the Geriatric Depression Scale (GDS). Following her recent ESRF diagnosis, Serena presented with a more pronounced symptoms of depression e.g. anhedonia, disturbed sleep, hopelessness, and a recent suicide attempt. The GDS is an effective screening instrument for determining geriatric depression and is practical to use in a long-term care population as the questions are easier for the residents to understand (Hartz and Splain 1997). Serena scored a total of fourteen making her mildly depressed at present (See Appendix). There are cases where a person might not be currently depressed but may have a very long history of depression (Hartz and Splain 1997). Although Serena only seemed mildly depressed using the GDS, it is imperative that the team looking after her would continue efforts to prevent her depressive state from worsening.

The client’s participation in his/her plan of care can help to increase a sense of responsibility and control (Schultz and Videbeck 1998). Serena is very much involved in the formulation of her plan of care. A section in her care plan entitled “I Am Who I Am” is completed by a staff nurse carrying out an informal interview with the objective of seeing the resident as a whole person in order to ensure their plan of care is meaningful for their needs and wishes. Serena has also a good insight into her illness, the reason why she agreed to temporarily stay in a long-term care facility. I have also conducted a series of informal interviews throughout my placement to gain an insight into Serena’s current situation as well as to holistically assess her needs and strengths. Gamble and Brennan (2003) suggested that with a formal assessment, client with serious mental illness often feel uninvolved in their care and thus, not reflecting their personal needs or aspirations.

DIAGNOSIS AND PLANNING
In our first meeting, I explained to Serena the purpose of why I was doing a series of interviews with her. Barker (1997) stated that when the nurse explains his/her intention to the client, cooperation is ensured right from the start. I went on by explaining to her the concept of confidentiality. Videbeck (2009) explained that confidentiality means respecting the client’s right to privacy and that allowing only those who are dealing with the client’s care to have access to the information that the client divulges. “If my experience will help other people who are going through the same situation as I am, I will be happy to assist,” Serena replied.

Because she has a history of suicide attempts with one as recent as a few months back, risk of suicide has therefore become the prime focus of Serena’s care. According to Videbeck (2009), a history of previous suicide attempts increases risk of suicide wherein the first 2 years after an attempt represent the highest risk period. In her plan of care, the long-term goal is to significantly reduce Serena’s suicidal ideation. The short-term goal is to ensure Serena stays free from harm. Determining her appropriate level of suicide precautions was immediately carried out on her admission to GLC and is continually reviewed and evaluated. Physical safety of the client is a priority and that the client’s suicidal potential varies; the risk may increase or decrease at any time (Schultz and Videbeck 1998). On one of the interviews, I made it clear to Serena that the staff in GLC will protect her from acting on suicidal thoughts and impulses. Knowing that protection from suicidal thoughts is always present helps the client gain control over suicidal impulses that may change in intensity throughout the day (Fortinash and Holoday Worret 2003). In addition, I also suggested to Serena to approach any of the staff whenever she experiences such suicidal thoughts. Constant staff support and protection reduce the client’s fear of suicidal impulses and offer hope for survival (Fortinash and Holoday Worret 2003).

Serena’s maladaptive coping due to depression is the other health concern identified. Long-term goal is for Serena’s symptoms of depression to be considerably reduced and will no longer interfere with her functioning. Short-term goals include (a) for Serena to learn effective coping strategies and (b) for Serena to actively participate in the activities offered in GLC. On several interviews, I’ve pointed out how supportive her family is and so as her CMHT, and how she’s good at knitting and painting. I’ve encouraged Serena to pay particular attention on her strengths rather than focusing on her weaknesses. The client becomes aware of positive qualities and capabilities that have helped the client cope in the past (Fortinash and Holoday Worret 2003). As much as she loves staying in her room, I’ve also suggested for her to remain out of it and to interact with other residents of GLC through the activities offered in the building. Socialisation provides opportunities to practice coping skills while reducing isolation (Fortinash and Holoday Worret 2003).

IMPLEMENTATION
A suicide risk assessment was already in place when I started working with Serena. Implementing the care plan that we have devised, I made sure that Serena and I gets to talk at least once per shift. I demonstrated genuine compassion to Serena that I do want to try and understand her situation with the use of communication techniques such as clarification, reflection, and validation. I’ve also talked to the rest of the staff to be extra sensitive when working with Serena i.e. not to joke about death, belittle her wishes or feelings or make insensitive remarks. I’ve also informed Serena about the facility chaplain and to make use of such service whenever she feels like it. She might be more comfortable talking to someone who is of religious authority. I have also linked with the activities coordinators of the unit, obtained a copy of the scheduled activities throughout the week. I would see to it that Serena would attend at least 3 group activities per week.

One issue that came up was not being able to link Serena to any of the day centres educating individuals about effective coping skills. It was difficult to do so as it entails asking permission from a long list of authorities. Instead, I was able to get her a copy of a couple of self-help books teaching readers about adaptive behaviours and problem-solving abilities in meeting life’s demands and roles.

EVALUATION
At the end of each week, the consultant psychiatrist would evaluate Serena’s condition and level of functioning. In addition, I would give the psychiatrist a weekly handover regarding Serena’s mental state and general wellbeing. Four weeks into working with Serena, I definitely saw an improvement in her condition. She now regularly attends every activity in the unit. She talks about the enjoyment she gets and the friends she has made. She has also organised a weekly visit to the oratory. She has also expressed optimism since being admitted to GLC. She verbalised that she’s looking forward to attending her niece’s wedding, a huge step given their family dynamics in the past. Her medication was also reviewed and an anxiolytic was added to her prescription for the treatment of her anxiety.

Serena is well aware that I will be leaving the unit in 8 weeks time. This is not the first time I’d be saying goodbye to her. She knows that she’ll be linking in with my preceptor once my clinical placement finishes. I continued to praise her on her progress, highlighting the positive changes I’ve noticed during my time working with her. In turn, she told me that she would keep attending the activities, read the books I suggested and to be as open as possible to the rest of the staff. “I want to get better, I want to go home to my family,” Serena said.

PERSONAL/PROFESSIONAL DEVELOPMENT
Caring for Serena, I have realised how difficult it is to listen to her without being subjective. I found it difficult not to show her sympathy and my own thoughts about suicide. As a devout Catholic where suicide is a mortal sin, I can’t get myself to understand why someone would want to end their life. Life can be unforgiving at times but whatever adversity one has to endure, it still doesn’t warrant a person to commit suicide. With the help of my preceptor and previous mentors from the psychiatric services, however, I have become aware and was able to work through my own feelings of disapproval about suicide. I also had this fear that since we were talking about her suicidal ideation, I might encourage her to ruminate and act on her suicidal plans. I’ve realised that in order for me to effectively deliver the care she needed, I had to put my feelings on the side and focus on the matter at hand.

This experience has influenced me both on a personal and professional level. Working with a person who has suicidal ideation has made me more aware of my own beliefs and limitations and how to work through it. This experience has taught me how to develop and plan a person’s nursing care. It has also given me the opportunity to work with a multidisciplinary team, confidently report and make suggestions regarding continuation of patient care. Should a similar situation arise, I feel confident enough to apply the knowledge which I have gained from this experience.

*To ensure confidentiality, name of client has been changed. References:
Barker, P. 1997. Assessment in Psychiatric and Mental Health Nursing: In Search of the Whole Person. UK: Stanley Thornes Ltd.

Cutcliffe, J. 2003. Assessing Risk of Suicide and Self-harm IN: Barker, P. (ed.) Psychiatric and Mental Health Nursing: The Craft of Caring. London: Arnold, pp.436-442.

Fortinash, K. and Holoday Worret, P. 2003. Psychiatric Nursing Care Plans. 4th Ed. USA: Mosby Inc.

Gamble, C. and Brennan, G. (Eds.) 2003. Working with Serious Mental Illness: A Manual for Clinical Practice. London: Baillière Tindall.

Hartz, G. and Splain, D. 1997. Psychosocial Intervention in Long-Term Care: An Advanced Guide. New York: The Haworth Press.

Schultz, J. and Videbeck, S. 1998. Lippincott’s Manual of Psychiatric Nursing Care Plans. 5th Ed. Philadelphia: Lippincott-Raven Publishers.

Videbeck, S. 2009. Mental Health Nursing. 1st UK Edition. London: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Zastrow, C. and Kirst-Ashman, K. 2010. Understanding Human Behaviour and the Social Environment. 8th Ed. USA: Brooks/Cole Cengage Learning.