Anita Kilroy-Findley: Tissue viability and mental health

I'm a mental health nurse by training and we're a bit of an aberration in tissue viability and when I started back in 1999 it was unheard of. I got into tissue viability because at the time I was a deputy sister on a dementia assessment ward and we had a lady there at At the time I didn't know, I now know she had a fungating wound to the groin, but I just remember that none of us knew what we were doing. This lady was dying on us with this fungating wound. We didn't know how to treat it, the smell was horrendous. It wasn't just a case of you could smell it in her room or the ward. You walked into the unit and you could smell that wound. Mental health patients are very different to the run-of-the-mill patients. I work with our community nurses now, the community tissue viability nurses, and some of the wounds they see are really big, dehisced abdomens or very large pressure ulcers, and we don't tend to get that in mental health. We do sometimes get pressure ulcers where patients are admitted to us with those pressure ulcers. And usually I help them manage those because they just, they're not taught wound care unless they've been on one of my study days. Self-harm's a big one for us and burns, burns is a lot because people who are psychotic and hear voices, especially command voices, often it's telling them to burn themselves. So I suppose are wounds, they are different, and I would say that they're not as complex if you just look at the wound itself in isolation, but if you add the patient in, they are complex. And it's about how do you work with the patient's beliefs, which can be difficult, and still achieve what you want. With self-harm wounds, one of the things I find is people need to look at what's the objectives around it, what does the patient want? And too often people don't do that, they just see the wound and the mantra is heal it, I will heal that wound. That's okay if that's what the patient wants but often they don't and the psychology behind it needs to be looked at and for a lot of people who self-harm, they're not mentally ill, that is their way of coping with deep psychological trauma that often is rooted in childhood and we see control is a big element around that. So if you have a nurse coming along saying, no, you're going to do this with your wound, no, you need to go to A&E and do that, you're taking that control away from them and that in itself is very psychologically damaging. So the really important thing with self-harm is to understand what does the patient want? Because if the patient still wants to be able to access that wound to harm themselves, there is absolutely no point having it stitched, glued, stapled or even putting on a dynamic expensive product because they want to get at it. So the best thing to do is to discuss with them, you know, a simple dressing that they can remove when they want to and talk to them about contamination and what are they using to damage it with. I mean, for inpatients, sterile forceps is my favorite, you know, give them some sterile forceps and if they want to fiddle with the wound they can. Contamination's a biggie because sometimes with self-harm wounds people just think, oh well if I take away all your stuff you won't self-harm. Well actually no, all they're going to do is go outside to find a nice rusty nail, that's always popular, a bit of glass and they'll just cut with that and you've got more problems because it's a gross contamination and then you're in that cycle of looking at the antimicrobial sector. What you tend to find with people who self-harm though is they don't go to healthcare professionals, they look after it themselves and sadly that is because of the negative way they are viewed by healthcare professionals and I saw somebody only two weeks ago who said that they didn't go because the last time they went they were told that they were taking up a valuable appointment slot of somebody else. So you can't blame them for not going and I think getting stuff published in some of the journals are you know if I write it it usually is on self-harm to try and get that knowledge out there of why it is so important and what what's behind it to get some empathy for people who self-harm because at the end of the day people who self-harm are very damaged individuals somewhere in their psyche. You do find people who present to services such as A&E and you can't say it's the same for all A&E services because there will be pockets of really good practice but certainly historically and some of what I hear from patients is they go to A&E and they are dismissed. It could be that their wound has been stitched, they've reopened it to re-harm and therefore the people in A&E dismiss them as either attention-seeking or not worthy of having the treatment because well we've already sewn you up once and look what you've done and what they don't appreciate is that attitude feeds into that person's negative thoughts about themselves, that they aren't worthy, that they are a bad person, and there's a failure to understand that when they originally had it stitched, they probably did want it to heal. You know, they did want it to move forward, but unfortunately, in that time span, something has happened that they couldn't cope with, that stressed them, and their only coping mechanism is to harm. And so they reopened it to harm. And there is that lack of understanding that it's not that they don't necessarily want it to heal. Some people do, some people don't. Tissue viability was unheard of in mental health. I was the only mental health trained TVN in the country. I'm hoping that's changed now, I'm not sure. Setting up a service, we started at the basics. I audited mattresses, for example, got a replacement program going, looked at the bed frames, started making sure that they were being audited biannually, we got a rolling replacement program, set up training for nurses in wound care. When I approached our local university, I was told that there was no wound care training in the mental health nurses program because they don't do wounds. And that shocked me because I just thought, yeah, and how long ago did you actually go on a mental health ward? Because of course we see wounds. You know, they might be slightly different, but we get them. So that was where it started. I introduced pressure ulcer risk assessments. We looked at what equipment needs we had for the different areas, bearing in mind it was all started in elderly. We looked at skin tear pathways and putting in education that people go on. I set up a linked nurse system and then when the post became full-time in 2005, I gained adult mental health children and we spread the work into those areas and we developed self-harm grab boxes so by that we mean there's a just a plastic tub basically but inside it is everything you would need to attend to a self-harm wound without thinking oh what's in the cupboard what have I got you know and when you've got nurses who haven't done the training and don't know what they're doing we have pathways pictorial pathways of you know if you've got a laceration this is what you need to do for this this is what you need to do for all of them. So it makes it no delayed treatment for the patient, nurses have more confidence in what they're doing and the patient has more confidence that the nurse actually knows what they're doing which is a huge part. And I also did the usual dressings formulary, evaluation, yeah.