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March/April 2017   Comments

Mental health nurses and PTSI/PTSD

Reading “First Steps in Creating a National Action Plan on Post-traumatic Stress Injury/Disorder” (Perspectives, January/February), I was very pleased to see CNA is working to ensure discussions about PTSD first-responder legislation include nurses. The article mentions that evidence shows nurses working in the ER, ICU, CCU and neonatal ICU are at increased risk for PTSI/PTSD. However, those who work in mental health were not mentioned. I think you will find they have the highest risk of being assaulted and, therefore, are at risk for PTSI/PTSD. Having worked in this field of nursing for 35 years, I have been exposed to and have been witness to violence, assault, suicide attempts and traumatic death. I have a good handle on how mental health nurses are perceived by their peers. I have been asked many times why I would work in this field and have been accused of not being a real nurse. I decided to write this letter because it seems we are being marginalized and thought less of than other nurses once again.

– Jennifer Brion, RN, BScN, CPMHN(C)
Toronto, Ont.


Prohibition at issue

It was timely that the articles on the fentanyl crisis and the challenges of research with medical cannabis appeared together (January/February). I recognize the limitations of a short article to fully explore the complex issue of fentanyl overdoses. By not addressing prohibition, however, we miss the obvious role it plays in this crisis.

Prohibition, intended to protect people from misusing certain substances, brings unintended consequences. For example, the academic research on use of psychedelics for treatment of addictions, depression, PTSD and end-of-life anxiety is compelling. But because the research is constrained by prohibition, the health-care community cannot legally access psychedelics to treat patients experiencing profound despair and psychological pain. The paradox is that these substances seem to be used more and more widely recreationally.

With revised prohibition, heroin could be prescribed more often for individuals with opiate addictions. Many of those who already access it through special exemption are stabilizing their lives, going to work and raising their families. MDMA could be available to specially trained physicians and psychologists to treat people with PTSD, many of whom are living with addictions. Recent legal research studies show great hope with a protocol of MDMA in combination with specialized counselling. Research could also be done on ibogaine, a psychedelic with a strong anecdotal history of interrupting and ending addictions to opiates.

With prohibition as it now stands, all the safe injection sites in the world and supersized buckets of naloxone on every corner will not end the fentanyl crisis.

– Gail Peekeekoot, MN, D.Min., RN
Crofton, B.C.


Update: Champions for the cause

We are jumping into 2017, as Marc Bourgeois (From the Editor-in-Chief, January/February) suggested nurses do! We are continuing our work to have non-state torture (NST) recognized in the Criminal Code. On March 16, we are speaking out about Bill C-242, an act to amend the Criminal Code (inflicting torture), at the UN’s Commission on the Status of Women meeting in New York City. We appreciate CNA’s support for the bill and being profiled in Nurse to Know (June 2016), which raised awareness of NST. We agree with Bourgeois’ comment that nurses’ voices make a political difference; sadly, the House of Commons standing committee on justice and human rights failed to support the bill. We strongly disagree with that decision, which reinforces the use of the euphemisms aggravated assault and aggravated sexual assault when referring to electric shocking; whipping and beating; inflicting psychological torture; immobilizing; suffocating; withholding food, drink and sleep; and repeated raping. Fortunately, we have seen some positive ripple effects from our work. The government mentioned torture recently in supporting the need to address Internet child pornography. This is powerful, given our belief that there cannot be public safety for children when their torture by non-state actors remains legally unnamed. Protection from NST is a specific human right, found in the Universal Declaration of Human Rights, which is referenced in the Code of Ethics for Registered Nurses and CNA’s position statement Registered Nurses, Health and Human Rights.

– Jeanne Sarson, M.Ed., BScN, RN
Linda MacDonald, M.Ed., BN, RN
Truro, N.S.


On the Choosing Wisely Canada nursing list

We have some concerns about the article on the first nursing list developed for Choosing Wisely Canada (Perspectives, January/February). Our first is that each statement in the Nine Things Nurses and Patients Should Question is written in the negative, i.e., don’t do this. It is not clear which action readers should question — the not doing or the doing. Our second concern is that the rationale and the evidence reviewed to develop the list weren’t included. Nurses are critical thinkers and these don’t do this statements take us back to a time when nurses did not question and were task-oriented.

Lastly, regarding recommendation 2: “Don’t advise routine self-monitoring of blood glucose between appointments for clients with diabetes who do not require insulin.” There are many reasons clients may want to monitor their blood glucose readings. Most certified diabetes educators advise clients on blood-glucose-lowering agents to monitor daily, at a minimum. For patients who are feeling the symptoms of a low or experiencing an illness, or to assess the response to lifestyle interventions and medications, we would advise routine monitoring.

– Daphne Wright, RN, CDE, CPT
Sara MacKenzie, RN, CDE, CPT
Melodee Dayrit, RN, CDE, CPT
Roselyn Wong, RN, CDE, CPT
Vancouver, B.C.

Congratulations to the nursing working group. The nine listed items are very relevant to clinical practice. I have spent the majority of my nursing career in geriatrics, and these items address issues clinicians face daily. Attempting to debunk myths to provide evidence-based care is never an easy venture. These nine points will give our recommendations more weight. Thank you for your insight in such important areas of care.

– Teresa Genge, NP
Edmonton, Alta.

I applaud CNA for being a leader in this important initiative. However, as a nurse with 30 years of expertise in diabetes, the lead author for the Canadian Diabetes Association’s clinical practice guidelines on monitoring glycemic control and an author of the association’s 2016 paper on driving and diabetes, I am troubled about the blanket statement made in recommendation 2. We are always concerned about hypoglycemia, especially in those who operate motor vehicles. We strongly encourage recognition, prevention and treatment of hypoglycemia in all people living with diabetes — not just for those on insulin but also for those on insulin secretagogues. During acute illness, hyperglycemia can also occur; this awareness is extremely important to guide clinical management for some individuals and to prevent hospitalization for hyperosmolar hyperglycemic state or diabetic ketoacidosis, an increasing problem in those with type 2 diabetes.

Self-monitoring of blood glucose has many functions in diabetes therapy and treatment. Directing patients who are not on insulin to stop testing routinely, without having a better understanding of the many exceptions, could be detrimental.

Lori Berard, RN, CDE 
Winnipeg, Man.

It is good to see CNA take leadership with the introduction of a nursing perspective to the Choosing Wisely Canada campaign.

I have been an outreach diabetes case manager for the past 13 years. I am a member of the Canadian Diabetes Association’s clinical practice guideline dissemination and implementation committee and a co-chair elect for the association’s Professional Section. My experience and appreciation for the complexity and challenges of chronic disease self-management have given me pause for concern with respect to the wording chosen for recommendation 2. I find this statement entirely too broad in its current form and worry that it will lead to poor outcomes for some people living with diabetes, along with diminished respect for the voice of nurses within this population. We must not discount the potential impact of self-monitoring coupled with meaningful conversation and support from a trusted, knowledgeable nurse.

The other eight recommendations pertain mostly to vulnerable populations, e.g., the acutely ill, the frail elderly or those with mental health issues. We can certainly find these types of patients within the diabetes population. I would argue that more frequent blood glucose monitoring can sometimes be a benefit to these people; for example, think of the frail elderly person with diminished renal function and dementia who may be on an insulin secretagogue. Hypoglycemia, in this person, can be masked. If the broad sweep of this recommendation is applied, we have most certainly placed him/her at great risk for falls and other serious consequences.

– Shelley L. Jones, RN, BScN, CDE
Salisbury, N.B.

Editor’s Note: In partnership with Choosing Wisely Canada, CNA is taking into consideration feedback from these readers and others. The Choosing Wisely Canada nursing list, the rationale for the recommendations and the evidence used to develop them are available at cna-aiic.ca/ChoosingWisely.


“Not in any way OK”

As one who has spent the past 30-plus years in nursing, I was dismayed by the casualness of the November Last Word, which focused on nurses’ new role in medical assistance in dying. I am struggling to understand how helping a patient end his or her life before natural death, which until recently was regarded as a criminal act, can now be considered good and valiant. Nursing patients through suffering and fear as they approach death is one of the ways in which we fulfil our moral responsibility of ensuring they have the best support we can provide. Whatever happened to the concept of assisting them throughout the entire dying process, encouraging them to express their feelings and concerns — and just being with them? It begins with compassionate palliative care and giving patients the opportunity to share their life stories, feelings, fears and, above all, hope, throughout their journey to a natural death. These shared encounters enhance the human experience for both nurse and patient. I disagree with the author’s suggestion that “it is all okay” when referring to the various emotions nurses will experience through their participation in MAID. There is a reason for the mixed and confused emotions. It is not all OK. The taking of a life before its natural time is not in any way OK.

– Fran Kavanagh, RN
Calgary, Alta.

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