Anita Kilroy-Finlay21st March 2013
Anita Kilroy-Finlay is Tissue Viability Nurse Mental Health and Learning Disabilities, Leicestershire Partnership NHS Trust
In the past, I used to drive a convertible yellow Beetle with ‘Mine’ emblazoned across the side, but, when I looked to get an identical car after losing my license for a short while due to ill health, the costs had risen prohibitively. So, I decided to get the gear and take to riding a motorbike, something I had always wanted to do. I travel everywhere on my bike, whatever the weather.
As I mainly work with inpatients I do not need to take equipment around with me, although I have just been given children in the community. Mind you, the patients in the community think it rather cool that the nurse turns up on a motorbike. These children suffer a variety of disorders, for example, a skin lesion around a tracheostomy site, which has suspected pseudomonas.
I also go to learning disability schools where some pupils have pressure ulcers. Here, I need to find out what they have at home in the way of equipment and give preventative advice. Focusing on pressure ulcer elimination and CQUIN is new for children’s services so my role involves a great deal of teaching about what is preventable. This has sort of sent a shockwave through the service as they have never done risk assessment before. I have had to implement the Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale and show the nurses what to do with the results.
I cover eight sites for inpatient care in mental health and learning disabilities:
- Eating disorders
- Huntington’s disease
- Learning disability respite homes
- Adult mental health
- Forensic mental health
- Challenging behaviour
- Young offenders.
As my memory is not great, I usually go to the office first thing in the morning to see where I am meant to be, and to check emails and messages and generally get to a clear point with an action plan for the day. Safeguards and incidence forms for any pressure ulcers, incidents or self-harm reported in the trust are automatically pinged to me, so these all need to be gone through. I have to follow these through with the ward to check that the correct care is in place, or start the root cause process if it is our fault. If it is an incident of self-harm, I’ll also need to check how severe and if any follow up is required.
A great part of my day is spent supporting nurses to feel empowered to look after the wound care aspect of patient care. Mental health nurses do not have a great deal of knowledge about wound management, despite the fact that this patient group are at the same risk of developing wounds as public in a general hospital.
One of the treatments that we do not instigate is negative pressure wound therapy (NPWT) because of the ligature risk or the risk of someone pulling at it, or even the pump being thrown about.
Most incidents of self-harm involve cuts, gouging or burns. I am lucky to have a very good relationship with the burn nurses with whom I share care. This means that patients can be discharged quicker to mental health wards, as the burn nurses know that I am there to pick up and continue the treatment regimen that they have started.
I think that I am the only mental health nurse who has invaded the world of tissue viability. This occurred because back in 1999 I was a deputy sister on a dementia care ward. We had a patient who died of a fungating wound to her groin — something I have never forgotten because of the smell that was apparent as soon as you entered the unit, not to mention the ward. At that time we had a service agreement for telephone advice, so no one actually came to see this patient. The sheer horror of this situation really affected me, prompting me to attend a community tissue viability nurse study day. This was my light bulb moment, as it became all too apparent to me what we were not doing and I put forward a proposal to do a day’s secondment once a week to learn the trade of tissue viability. Thereafter, I set up a wound care service within the dementia care unit and in 2005 this became a full-time post to cover all mental health and tissue viability services within the trust.
Tissue viability is still underrepresented in mental health despite the fact that people with mental health disorders are three times more likely to develop type II diabetes, are less likely to engage with their local primary care trust and far more likely to develop complications of diabetes. As a result, I also have a good relationship with the diabetes nurse specialist and we do joint reviews and she’ll even come to the unit rather than expecting the patient with mental health issues to go to her clinic. These links with others in the multidisciplinary team, although probably unofficial, really help in my day-to-day work.
My caseload is on the whole quite small, but variable, in that it will be those patients who have wounds that could be challenging for the nurses, or wounds which I want to keep an eye on — possible infection or if the patient is problematic. It is interesting that patients with mental health disorders often respond better to me than the nurses on the ward, as I am seen as an outsider, the expert.
With some of the patients being problematic, the nurses need support. I put in quite a bit of time for assessment so that the ward nurse knows what they are doing, what treatment to use and the clinical rationale behind the regimen — my advice ranges from dressing selection to any extra holistic advice. Treatments are always discussed with the patient, as it is particularly important with this patient group that they buy into the regimen chosen. There are occasions when patients do not buy in and this can open up a whole host of problems. For example, the case of a lady with bilateral cellulitis and wet gangrene who was coming in and out for intravenous (IV) antibiotics. During the times when she was unwell she would not let anyone near her legs and had no idea as to the risk that they posed. The only way to examine and treat her would have been to restrain her, which, of course, was unacceptable. You cannot section for physical care, and so sedation was the only other possibility, but this would have needed to be done under the Court of Protection. Even with this, there was always the very real possibility that the lady would remove any dressings afterwards. The worse case scenario of such a situation is septicaemia — so, what do you do?
I am also secretary to the regional TVN group and take the minutes, which I enjoy doctoring to see if anyone notices!
Visiting prisons is another new part of my job and I am still feeling my way around a bit. The prison is for ‘lifers’ so I need to liaise with the link nurse and find out what equipment they have and see what screening is needed. I have got the young offenders unit under control, with most cases there being self-harming.
Integrating everything is crucial to my role and I have adapted the Waterlow scale, with Judy’s permission, to align with this patient group by including mental health drugs that dull the central nervous system and mental health conditions that affect neurological function.
As the interview concluded, Anita complained about the rain that was coming down, but she was still going to get on her bike and ride home.