Mental Health

I just finished reading a book called “Madness: a memoir” by Melbourne doctor, Kate Richards. It’s an honest and poignant account of her experience with mental illness. She ends the book by saying…”I’m grateful to be living in a country where medication and therapy are mostly available and affordable. However even in Australia, we are still not caring for the most vulnerable members of our communities. Those who, through no fault of their own, are not as lucky as I have been to respond to medication or to be able to find the right kind of therapy. These people are of all ages and backgrounds, and we ignore their suffering because most of us don’t understand their ways of seeing the world or we are afraid of their difference or embarrassed by their appearance and because we don’t see their injuries. No-one ever wakes up one morning and thinks, today I’d like to go mad, lose my job and friends, and end up odd-looking and living on the streets, anymore than they think, today I’d like to get cancer.”

Aurukun has the highest number of mental health clients in Cape York and is serviced well by visiting mental health teams. The RFDS built a Wellbeing Centre (pictured here) in the grounds of the clinic a few years ago which offers support, counselling and education. But providing services is just one way to support “vulnerable members of our communities”, having, and showing, kindness and compassion, firstly on ourselves in our demanding work as remote area nurses and then to others is the key to our continuing mental health and our patients healing.

The Royal Flying Doctors

100_8090Every Australian knows what the RFDS is and what work they do. Every remote area nurse will at some stage in their lives have looked longingly at the sky to see the first glint of silver approaching or strained to hear a faint engine rumble along with hopes that their patient would stay stable during the wait.
During the two years I worked in Aurukun and later in other far away places it was the knowledge that the RFDS was only a phone call and a flight away that enabled me to work without overwhelming fear. I still marvel at it’s history and the initial concept of a “mantle of safety” covering outback Australia. What a man of vision John Flynn must have been. Barely a day went by when I worked in Aurukun that I didn’t enjoy working in partnership with the RFDS staff based in Cairns. I think as Australia Day comes around again the RFDS can be numbered among our local heroes.

Sleep Deprivation

When I applied to work in a remote clinic I assumed that being on call after hours would be like doing night shift. It wasn’t. With night duty you know what hours you are rostered to work, with remote area after hour call outs, nothing is certain. You quickly learn that you could be woken up several times a night, rarely for real emergencies.Nurses are often told to educate the community on what an emergency is, but at 3am arguing with someone who’s woken you with a toothache,simply guarantees that you lose more sleep than if you just get out of bed and go and see them.

The US National Sleep Foundation recommends that adults need between seven and nine hours sleep a night. Continued lack of uninterrupted sleep results in sleep deprivation with potentially fatal effects.Remote area nurses usually have fatigue leave (if they don’t work in a single nurse post) which is supposed to make up for lost sleep. While we all value it, it is rarely a substitute for sleep. If staffing is short or clinic demands many, a nurse repeatedly on call can be functioning at a much reduced level of competence. When important decisions have to be made for patients health one has to wonder if the added responsibility put upon them to “educate” the community about what an emergency is, is a wise thing?

Among the many results of lack of sleep are an increased risk of accidents and injury, impaired attention, alertness, concentration, reasoning, memory and problem solving. It can lead to health problems such as heart disease, stroke, diabetes and depression. Judgement can be impaired, especially in regard to being able to assess what lack of sleep is doing to oneself. Also hurting their ability to make sound judgments because of a reduced ability to assess situations accurately and act on them wisely.

Before deciding to work in remote areas nurses do well to assess how well they function without sleep.

Fatigue Leave

Most nurses who work in Australian remote locations have to take turns at being on call for emergency after hours call outs, from the clinic where they work. If a community is large, or staff few, a nurse can quickly become exhausted from being called out several times during the night. In Queensland a nurse is allowed a 10 hour break from any call out after midnight, it’s called fatigue leave and is a welcome relief, to sleep in and just stay at home.

Here’s an excerpt from my journal in late 2008:
” On call last night, did overtime with a vomiting child, a nose bleed that had stopped by the time they got to the clinic, a cut foot and a crying baby. I got into bed after midnight…now enjoying the luxury of fatigue leave, sitting in bed with coffee, books and my own company. I’ve opened the curtains to let light in. I can see straight out onto the clinic grounds, the wind is scattering gum leaves and dried palm fronds, sunlight and shadows making interesting patterns through the eucalyptus trees when I half close my eyes, all from the safety of my bed, my haven. This is day number six in a nine in a row stint and I’m already weary of people and their needs.”

Cultural Awareness

My experiences of formal cultural awareness programs is limited to three. The first was a two day compulsory program provided by Queensland Health in the nineties. I worked in a paediatric ward of a base hospital, occasionally I cared for an Aboriginal child but rarely had contact with a child’s carers. Usually older siblings were sent up to the ward to visit and police were asked to find parents when it was time for a child to be discharged. I assumed Aboriginal people weren’t comfortable with hospitals. The two days I spent in a classroom hearing the history of the crimes of the dominant white culture against Aboriginal people didn’t give me any insight at to why I rarely saw the parents of Aboriginal children visiting in the ward. Was it a distrust from years ago?

The second cultural awareness talk was less formal but one I was hoping to learn valuable information from. It was two days after I arrived in Aurukun to work with Aboriginal people in the health clinic. I knew I needed to learn about the local culture. The senior health worker took me to a private corner of the room to give me a cultural awareness talk and said “Sometimes a patient comes into the clinic and they might be poison to a health worker.” I’m sure my mouth dropped open and my eyes widened…I asked “What makes one person poison to another?”…after a meaningful pause and a long sigh…the reply was “it’s always been that way.” And with those few words he stood up to leave, having given me the talk. His words left far more questions in my mind than I had before he spoke to me. It was many months before I had any idea of what he was talking about. The little I learnt about local culture was taught informally by the two female health workers on a need to know basis.

The third experience was a whole day at the Alice Springs hospital last year as part of their orientation program. It was run by a local Aboriginal woman. I learnt about kinship systems, cross-cultural communication, local history and language. It was fascinating and informative but by that time I’d already learnt much of it through my own reading, watching films and listening and paying attention to Indigenous people around me who’d been open enough to talk about their lives.

Education is an interesting thing, it can be both formal or informal and come at the right time to be understood and benefitted from, or a lot of money and time can be wasted on irrelevant information badly timed.

Security

090Before I flew into Aurukun the Director of Nursing at the Health Clinic told me she employed two Tongan security guards to keep the nurses safe in the clinic on after hours emergency call outs.

When I arrived in 2008 I was taught how to lock the ambulance securely in a shipping container. Prior to that idea ambulances had been stolen and wrecked by local youths hungry for adventure.

I soon became accustomed to carrying several keys for various secured doors and the padlocks of closed heavy metal gates.

The word security means the state of being free from danger or threat, it comes from an old Latin word, securitas, which means “free from care”.

Aurukun over the past 20-30 years has had a history of violence, riots in the streets and fighting between families and clans. The reasons are too many and complicated for this post. But it’s resulted in the need for high security measures for all who work there.

It’s an odd thought that to be safe and free from care actually requires a large amount of resources, planning and attention. It’s just another paradox I’ve encountered as a remote area nurse.