International Nurses Day 2020: Case study of the week
21 July 2020
Child and adolescent psychiatry in Western Lapland, Finland
Contributor: Marianne Karttunen
Western Lapland in Northern Finland has a population of about 62,000 people served by a 22-bed psychiatric hospital and six community psychiatric teams. About one-third of all psychiatric staff (approximately 150 people) are stationed in the hospital and half in community care, but many of the hospital staff do outpatient work as well. In the smaller municipalities of the region there are also local mental health teams who collaborate in teamwork around the patients and their families.
For many years, we have been using the Open Dialogue system of care, an approach in which clients and their families are regarded as active participants in the planning and implementation, rather than as objects, of treatment.
The goals of this approach were to develop a comprehensive family- and network- centred psychiatric treatment model on the boundary between outpatient and inpatient care systems. The aim is to respond promptly to crises, while trusting in and supporting the resources of the family and other close network members. From the outset of treatment, attention is paid to carefully listen to the concerns and hopes of the people involved in the treatment so as to enable dialogical interaction. Child and adolescent services do not have any hospital beds in our area, so treatment and care are offered in people`s own natural environments. When hospital is needed, we work with Oulu University hospital and Rovaniemi youth services.
The core idea of our psychiatric services is based on a collaboration. There is an active stance in creating and maintaining the dialogue with partners in the community, including social services, schools, youth workers, congregations, the hospital ward for children who are physically sick, the police, adolescent services and the Oulu University hospital.
Our healthcare system requires equal agency from everybody, despite their professional role. To that end we have created a three-year scheme for all professionals, which has strengthened nurses’ professional identity and created own culture over the past 30 years.
Nurses are independent agents in our service, who assess and are active agencies in conducting the care. They use their nursing, therapeutic and dialogical skills when working with each other, and with clients and their networks.
As there are no hospital beds in child and adolescent psychiatry, nurses hold great responsibility in assessing the emergency and need for the treatment in first contact. They need to have an understanding about the local networks and the resources available for collaborative work.
We use the elements from systemic thinking, where we see crisis situations as efforts to solve problematic life situations in a way that is meaningful for clients/patients.
Our service is based on seven principles:
- Immediate help: There is no need for a referral for access to treatment and any individual or network can contact the service, usually by telephone. The need for treatment is decided in a joint conversation, with nurses organising the treatment team and process from the first contact. The team is made up mainly of nurses, and medical assessment or diagnosis are not seen as the primary focus in the meeting; instead, the team listens to various concerns and perspectives, and responds to them.
- Family and network orientation: Family and other close social network members are considered a key resource for understanding and supporting individuals in crises. Working with families and networks requires different kinds of orientation and skills compared to the individual nurse-patient relationship that can be emphasized in traditional psychiatry/nursing, so we have provided a three-year dialogical family- and network based training for the whole staff.
- Responsibility: Shared responsibility means that all team members bring into consideration various important issues during the process, including safety around different treatment decisions, concerns around suicidality, safety during the sessions for all people to express their own, even opposing voices, and that all issues raised are responded to. The trust required between the team members is developed by working together, through team supervision and weekly team meetings where issues regarding the collaboration are openly discussed.
- Flexibility: Each client and family needs the most appropriate, need-adapted approach to their treatment. At first, appointments may be daily, and subsequent appointments and who should attend them are agreed and scheduled at each appointment. This need-adapted approach requires flexibility from the team, and on many occasions team members have to reschedule their timetables to enable the intensive work in a crisis situation.
- Continuity: Treatment can last several years so the responsible team creates the therapeutic relationship with the client and relevant network members, and takes care of the process of care and fosters psychological continuity. If the client needs temporary hospitalisation, the outpatient team remains in charge of treatment, despite the team being temporarily supplemented by hospital staff.
- Tolerance of uncertainty: Crisis situations easily arouse anxiety in team members and in family members, too. This can lead to team members hastily providing solutions to resolve a difficult situation, taking responsibility for the situation and ignoring the client and their network’s agency, and their own skills to alleviate the situation. We consider the family and other close network relations as potential key resources of understanding and support for individuals in everyday life. Listening to them carefully and thinking about different views can lead to solutions that support the network members’ own abilities to act in crisis situations. Decisions about long-term medication are taken only after several conversations about their merits.
- Dialogism: The main goal of the treatment is to create a dialogue between the participants and their different internal voices. in dialogical meetings a shared interactional space is created where the possibility of change is evolving through the exchange of utterances and responses. It is important for team members to listen carefully to the different words and expressions in a network meeting, and respond to the expression of emotions. The use of words should be adjusted to the ones used by network members, and medical or psychological terms should be avoided.
The system of care in Western Lapland is unique in that it provides help for people with lowest threshold as possible and the service is run clinically mainly by nurses. At its best, long term psychiatric medications are not needed in a way that traditional psychiatry is using them, and this can lead to better outcomes in recovery and building empowerment in individuals and families.