Understanding Depression: A Case Study of Ms Jessica and the Role of Nurses in Public Health Promotion

This essay discusses the case study of Ms Jessica to understand how depression affects a person’s overall life. It also highlights the role of nurses in public health promotion and the importance of communication in nursing practice. The essay suggests evidence-based health promotion strategies for Jessica and identifies the responsibilities of mental health nurses.

Introduction
Depression is one of the leading mental health issues across the globe (Vos, et al.,
2013). In 2013, depression was the second chief cause of years lived with a
disability worldwide, only followed by lower back pain. Depression was the key
cause of disability in 26 nations (Ferrari, et al., 2013). The sign and symptoms of
depression can vary from mild to severe. It can disrupt an individual’s routine life.
The clinical manifestations not only affects the mental state but also engulf the
physical sphere. In this essay case study of Ms Jessica to understand how the
clinical condition of depression affects a person’s overall life. Evidence of health
promotion are also used to discuss the nursing practice. Role of nurse in public
health promotion is also identified. Then the concept of communication related it to
nursing and nursing practice is defined. In addition, two areas of the communication
skills that that needs to be developed are also identified to inform an action plan for
future practice.
Case Study
Ms Jessica was brought in the psychiatry department through a referral by her GP
with suspected diagnosis of depression. She is a 52 year old lady who is employed
in a firm as an accountant. His husband died last year due to prostate cancer. She
now lives with three kids, a son in college and two daughters in school. A
psychoanalysis was conducted and her family were also enquired. On asking her
eldest son regarding his mother’s mental status, he got emotional and told that
since the death of his father, his mother has experienced increased physical and
mental stress because of enhanced responsibility and the loss of her constant
support. Jon was given time to compose himself and then he was made to
understand that it is natural of her mother to react in this way and she needs time
to adjust to the void that is created in her life. Jon also revealed that his youngest
sibling Jean was very close to her father and his mother found it very difficult to
manage her after his husband’s death. Her daughters informed that she kept
looking at a spot and doesn’t react to anything. On enquiring her kids, it was
concluded that they were a happy family and the trigger point of Jessica’s
depression was her husband’s death as she was finding it challenging to cope up
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with this incident. Since he suffered from prostate cancer, last few months of his life
were also very difficult for Jessica and the kids. So, she is living under physical and
mental stress from around last two years.
Notes from her GP enlisted multiple changes that were observed by him in Jessica’s
behaviour. Due to her constant absence at work, she left her job as an accountant.
She neglected herself. She even said once she has suicidal thoughts at times. On
one occasion, she left her house without informing anyone and didn’t return till late
night. She came back with injured hand and multiple injuries. She refused to come
to the hospital and asked her kids to stay away from her.
During the psychoanalysis it was found that Jessica and her husband spent their
savings in the treatment of his care and she is facing financial burden due to lack of
financial resources. It was found that she was very worried about the future of her
kids and that she has to fulfil their requirements. Her mental state also revealed
that she was overthinking about her kids and lack of father in their lives. During the
psychoanalysis also, she was reluctant to talk but didn’t look aggressive. However,
she cried three times in the entire session. She was consoled and given time to
relax herself. It was observed that Jessica was calm, cooperative but sometimes
unresponsive during the entire session. Jessica was neglecting her professional and
personal responsibilities. She also did not look after the home and her own hygiene
and looks.
Public health promotion to Jessica
Ms. Jessica faced the issue of suicide ideation which is considered as a key cause of
mortality in public mental health issues like depression. Two items of evidence one
quantitative, and one qualitative are chosen from the current literature that could
be used in helping to inform Jessica with regards changes to her life style. Summary
of both the articles can be found in appendix 1.
Appendix 1 Summary of two items of evidence
Lifestyle psychosocial interventions are linked with severe mental illness, and
suicidal tendency in recent times. Patients with mental health issues have increased
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mortality rates, inferior health states, and increased suicide tendency as compared
to the general population like in case of Jessica. Lifestyle conduct are responsive to
change by adopting particular psychosocial interventions, and numerous
approaches have been used. This evidence offered a detailed review of the
literature on lifestyle interventions, mental health, and suicide risk in the general
population and in patients with mental health disorders. Multiple factors can provide
rational for the link between lifestyle behaviors and suicide. First, several studies
have found that certain lifestyle behaviors and its results (sedentary lifestyle,
cigarette smoking underweight, obesity) are related cardiometabolic risk factors
and with poor mental health. Second, several lifestyle behaviors may lead to social
isolation, limiting the development of social networks, and remove individuals from
social interactions; boosting their likelihood of occurrence of mental health issues
and suicide. Jessica must be encouraged to have an active lifestyle by going back to
her job and looking after the kids and home. She must also be encouraged to build
social networks by meeting new people or contacting her old friends (Berardelli, et
al., 2018).
A study was conducted to evaluate if brief intervention and contact is useful in
decreasing subsequent suicide mortality among people who have tendency of
suicide in low and middle-income countries. It was found that substantially fewer
deaths from suicide took place in the brief intervention and contact as compared to
in the treatment-as-usual group. The inexpensive brief intervention can be a
significant part of suicide prevention programmes for people who are facing
financial issues like Jessica. The brief intervention and contact indicated that
universal and selective suicide prevention strategies must be supplemented by
indicated strategies. Focus must be laid on Jessica by offering her psychosocial
counselling and supportive ongoing contact as it can substantially decrease
mortality because of suicide. One of the chief benefits of brief intervention and
contact is that it needs little training, as compared to the high-skill training that is
typical of more advanced psychotherapeutic treatment like cognitive-behavioural
therapy. Since it is low cost, it can be performed with minimal resources of space,
equipment and personnel (Alexandra Fleischmann, et al., 2008).
Nurses have a vital role to play in public health promotion. Mental health nursing is
a specialised area of care practice which promotes mental health through
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assessment, diagnosis and management of individuals with mental disorders. The
mental health nurses have several roles to play in contemporary mental health
nursing (Thomas, 2016). They are required to have a clinical competence based on
interpersonal strategies and nursing process (Cleary, et al., 2012). They are
expected to be a resource person who can provide all the required information
regarding health to the patient like Jessica and her family must be accurately and
adequately informed about her condition by the nurse. They are also supposed to
be a teacher who can assist the patient in learning and growing in the healthcare
setting. They are also expected to be leaders who can lead Jessica in the right
direction and guide her to participate in the process (Cleary, et al., 2015). They also
act as counsellor by helping the Jessica integrate facts and emotions linked with an
experience into her quality of life. The mental health nurses also need to perform
the emotional labour apart from the physical work. Mental health nurses are
expected to deal with patient’s attitude, mood and their perception of reality. They
also explore patient’s conflicting and disturbing emotions. The nurse-patient
partnership includes several aspects of a mental health nurse’s role in the
healthcare system. They need to acknowledge the advocacy needs of patients and
their families. They are also required to be responsible and sensitive to the social
environment (Powell, et al., 2015). They need to understand the thorough
consideration of the legal and ethical dilemmas that a mental health nurse faces
frequently during practice. They should be skilled in interprofessional collaboration
based on mental health nurses’s clinical competence, professional self-assertion
and a clear understanding of the cost of mental health care and mental health
nursing (Zugai, et al., 2015) 249-257. Direct care, communication and management
are the three primary domains of the contemporary mental health nursing. These
three domains involve the roles of teaching, coordinating, delegating and
collaborating functions (Morrissey, et al., 2011). These are the responsibilities that a
mental health nurse is expected to fulfil to perform the job well. The emotional work
is associated with the stress from interaction with the patients and from routine
daily tasks. The mental health nurses are expected to have certain intrinsic belief
like treating everyone with respect and dignity, protecting autonomy and self-
actualisation, potential of change, equal opportunity, non-discrimination and non-
judgemental conduct. The nurses are expected to communicate hope in the Jessica
and her family (Cleary, et al., 2016). They are expected to build a personal
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relationship with the patients to apply and achieve the goal of nursing process.
They are expected to involve Jessica in her care planning in decision-making. The
nurses are expected to develop a personal deep relationship with the Jessica which
leads to experience of several emotions and thereby increases the emotional labour
(Sant & Patterson, 2013). Apart from the above mentioned roles and
responsibilities, the mental health nurses perform several other particular tasks like
relapse prevention, nutrition counselling, discharge planning, family interventions,
documentation of care, forensic testimony, report preparation, verbal reports of
care, staff meetings, risk management and telehealth (Nursing and Midwifery
Council, 2015).
I must be competent with all the theory and practice lessons to fulfil my
responsibilities as a nurse. I should be able to integrate the theoretical lessons and
evidence gathered through research into nursing practice. I believe one of my
strengths is my good communication skills as it comes naturally to me. I have
practiced verbal and non-verbal communication techniques thoroughly. Since good
communication is one of the primary requisites of effective nursing practice, I
believe it will help me immensely in my work. I may face difficulty in teaming up
with professionals of other departments but nurses are required to deal with a
range of professionals from multiple departments so I must develop and improve
the collaborative skills. I must practice continuous professional development in
order to keep improving in my job role.
Communication
Appendix 2 Communication Appraisal Form
Name:
Student Number:
Me- Good Morning Ms Jessica. My name is XYZ and I am your mental health nurse.
Jessica- Good Morning XYZ
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Me- I am here to ask you a few questions regarding your physical and mental health
conditions to gain a better understanding of your problems. If I have your
permission, shall I go ahead?
Jessica- Okay!
Me- I am sorry about the loss of your husband. Please accept my condolences. I am
sure he is relieved of the pain and is in a better place.
Jessica- I am sure he is. Thanks.
Me- Tell me Jessica, since this incident, have you lost interest in doing daily routine
activities?
Jessica- Keeps silent
Me- Okay Mary tell me about the physical discomforts you are facing.
Jessica- I don’t know. There are many, nothing too much though.
Me- go on
Jessica- I don’t know. That’s it.
Me- okay then tell me. Tell me about the complaint of physical exhaustion you are
having?
Jessica- Yes, I feel tired all the time every day, even if I am not doing any physical
activity.
Me- hmm (nodding head)
Jessica- It’s like I don’t have energy left in my body. And even after feeling so
exhausted I have trouble falling asleep.
Me- Okay
Jessica- it’s like as soon as I reach bed, I start feeling down and hopeless.
Me- Jessica please answer, on a scale of 0 to 10, 0 being I don’t have any interest in
doing everyday tasks and 10 being, I completely perform all my daily routine tasks.
Jessica- I think a 5 as I feel that way on nearly half days of a week.
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Me- Jessica, how are you feeling currently?
Jessica- nods head
Me- Mary, I want you to answer how are you feeling right now?
Jessica- I am feeling okay.
Me- Considering that you feel hopeless, do you ever have suicidal thoughts or
thoughts of hurting yourself?
Jessica- only a few times after the death of Ian, not any since last 4-5 months.
Me- that is very good news. This is definitely a sign of improved mental health. Okay
I see I have all my answers. We’ll meet tomorrow with the results and take it from
there.
Jessica- okay thank you.
Descriptor Student Reflection
Did I convey warmth,
genuineness, empathy,
unconditional positive
regard?
I believe I was warm and empathetic during the conversation.
Did I display verbal
fluency? (appropriate
speech, pace, and
tone)
Yes
Did I display
appropriate active
listening skills?
(Demonstrating this by
using appropriate
nonverbal and verbal
communication).
I believe I may have got impatient with Jessica’s silence
Did my verbal yes
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communication contain
appropriate reflections,
clarifications and
paraphrasing?
Was I sensitive to the
patient’s emotions,
responses and
feelings?
yes
Did I consider cues
from the client that
indicated a degree of
flexibility, or a change
of direction or the
termination of the
communication?
yes
Did I use summary
reflection to mark the
end of communication
and allow the client to
feedback their view
point?
I gave a positive reflection in the end along with explaining
the course of therapy
Did I consider carefully
the possible barriers to
communication and
make the necessary
adjustments in order to
consider these?
(Barriers may be
language, poor
concentration, memory
impairment , physical
discomfort etc)
I ensured that there are no barriers during the entire
communication
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I tried to develop an effective caring conversation with Ms Jessica by not only
stressing on improving her health status but also laying importance to her way of
life. I focused on her recent loss and the grief and influence it had on her life. I
maintained an understanding, empathetic behaviour during the session. I made
sure that she felt she is not being judged and her privacy is not violated by having
an open and honest conversation. To take consent prior to commencing our session,
I used suitable communication skills to explain the goal, procedure and result of the
session. It is vital that Jessica felt supported in making their own decisions. I felt by
being empathetic, I made Jessica feel relatable which gave me access to her true
feelings and thought process. According to roger, congruence, unconditional
positive regard, and empathic understanding are the three core conditions of the
person-centered approach to psychotherapy (Rogers & Rogers, 2012). Congruence
signifies that the practitioners are genuine and authentic, not like the “blank
screen” of traditional psychoanalysis. Unconditional positive regard means
fundamental acceptance and support of a patient, irrespective of in which way the
patient talks or acts. Empathy implies to accurately understanding what the patient
is feeling by stepping into his/her shoes. I felt that by using these three conditions
throughout my session helped me in obtaining psychoanalysis of Jessica’s case. I
assisted her in understanding the importance and developing certain personal goals
for herself like maintaining hygiene, being more expressive and meeting people of
her social circle.
The primary objectives of a communication between healthcare professional and
patient suffering from emotional distress are developing a good interpersonal
relationship, making an exchange of information, and involving patients in decision
making process. By adopting a patient-centered approach for communication,
practitioners can exchange information in a humanistic and empathic way without
compromising the vital components of biomedical information. The incorporation of
psychosocial components of treatment adds to an ideal biopsychosocial model of
patient care (Mead & Bower, 2000). Evidence suggests the significance of
highlighting the experience of patient’s illness and not just treating the disorder.
Patient-centered communication wants the physicians to modify the biomedical
approach to care by assisting the service users feel understood by reviewing their
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requirements, perspectives, and expectations, by addressing the psychosocial
context and by extending patients’ inclusion in understanding their illnesses and in
decisions influencing their health and care outcome (Epstein, et al., 2005). An
appropriate communication involves both the patient- and practitioner-centered
approaches and a more patient-centered communication leads to better patient as
well as healthcare provider satisfaction.
The communication between healthcare professionals and patients who experience
emotional distress can be very complex. Patients who are depressed, distressed or
anxious may show resistance in conveying their emotions to the care practitioner.
Patients may abstain from explaining their experience to their mental healthcare
specialist due to the stigma attached or stereotypes about emotional problems.
From my experience of Ms Jessica’s case, I leant several lessons. I learnt the value
of healthcare provider-patient relationship in practice. I learnt that every individual
with psychological problems is unique and has different underlying deep-seated
causes. The practitioners should not only focus on working with the protocol of
treating the patient’s current condition, instead they should attempt to gain trust
and gather information from the patient and involve them in every step of decision-
making and care planning. I also learnt that there are several theories, models and
approaches available to develop effective communication and it is very important
for the practitioners to select the accurate model after identifying the patient’s
condition and needs. The healthcare providers should be empathetic, respectful and
genuine towards patient, irrespective of patient’s response. Like in Jessica’s case,
she was very reluctant to talk and open up with me. I tried using different
approaches to open her up. I noticed when I used broad opening statement; she
took this as an opportunity to the patient to express herself which taught me it is
important to not directly ask the questions from the questionnaire but to make a
general statement related to the topic of question. I will keep this in mind and use
this technique in future with patients who are resistant. And while she was engaged
in talking I gave the general leads like yes or go which made her continue talking. I
learnt that the small leads and gestures convey to the patient think that the
practitioner is listening attentively which is very important to develop active
listening skills. Since she didn’t want to disclose much and refrained from talking, I
faced difficulty in getting information from her. In future I would take silence as an
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accepting attentive tool to allow the patient to reflect upon his/her thoughts and
then speak again. I also noticed that she stopped talking only after when I gave her
continuous reassurances. I will refrain from giving repeated reassurances to such
patients in future as it may discourage them from expressing their feelings in fear of
their emotions being not understood. I learnt that it is vital for practitioners to be
very careful in not suggesting their approval or disapproval in any way to what the
patient has said. I also learnt that pushing the patients for answers of certain
questions may lead to them feel used and regret what they have already shared. In
future I would not push my patients for answers immediately instead would come
back later to it so that they don’t feel used or overwhelmed. I learnt the importance
of not giving advice on selection of the therapeutic outcomes instead providing
guidance to the patients to select the outcomes they want in their life and they feel
important.
From the self-assessment, I identified two spheres of my communication skills that I
think require improvement are as follows:
1. Development area/objective – Active listening skills
First domain of improvement according to my past experience will be to
integrate active listening skills in my communication style. One of the
barriers to effective flow of communication is not listening effectively to the
patient which I observed in Mary’s case I also face. In future, I will ensure that
I begin talking only when the patient is comfortable. I will also focus on
improving my body language and mannerism to exhibit my interest in what
patient is talking. I may require some lessons and training for that from a
mentor. I will refrain from interfering when the patient is expressing
himself/herself (Ranjan, et al., 2015). I will refrain myself from giving
repeated reassurances to the patient which might seem fake to him/her and
instead practice silence to give opportunity to the patient to talk. I will make
efforts develop a dialogue between me and the patient which is driven in a
common direction (Berman & Chutka, 2016).
2. Development area/objective – Eliciting information
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My second area of improvement will be the learning skills and strategies to
handle resistance from patients and obtain required information from them. I
also faced difficulty in eliciting information from Mary so I want to work on
this area to improve my practice. Resistance from patient’s side to reveal
their worries and disclose information is very frequently seen in practice. I
will try to enhance my information eliciting skills by enquiring in an open and
non-judgemental way to develop openness with my patients. I can use post-
treatment feedback forms available in the hospitals to gain a review about
my performance from patients. I can also take feedback from nurses or other
staff about my communication skills. The patient-centered interviews involve
open-ended questions which enable the patient to take enough time to
respond to the questions, and encourage a more precise account of the
patient’s symptoms. I will be take caution to not pass any discriminatory or
other judgemental comment on patient’s condition unintentionally, that could
stop him/her from talking. I will train myself to respond to patient reactions
by role playing. I will understand the reaction/response, provide sufficient
time for expressing their emotions. I will actively and quietly listen to
patient’s talk. I will be mindful of my body language so as not do dissuade the
patient from sharing information.
Summary
Jessica suffered from possible depression which not only affected her mental health
but also her activities of daily living. Jessica and her family was enquired and a
psychoanalysis was done to understand Jessica’s clinical condition and how it
affected her life. She was treated compassionately as she was already under mental
stress. She experienced issues like neglect, self-neglect, suicidal risk, etc. Jessica is
encouraged to build social networks and get involved in different activities including
fulfilling her professional and personal responsibilities. These lifestyle changes will
help her in reducing the risk of suicide attempt. Nurses have several roles to play in
contemporary mental health nursing. Person-centered communication which is
based on, congruence, unconditional positive regard, and empathic understanding
can help Jessica in the psychotherapy. Adequate, effective and compassionate
verbal and non-verbal communication must be done in order to build an
interpersonal relationship with Jessica.
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