It was a patient at an HIV clinic in San Francisco who made Kate Melino decide to head back to school and get her PhD in nursing, awarded today at U of A’s convocation ceremony.
Melino was working as a psychiatric mental health nurse practitioner when “Robert” came in asking for help with insomnia, but she soon realized he needed so much more. Robert had undertreated HIV and cardiac problems, an addiction to methamphetamines, no safe place to stay at night, depression and anxiety.
She could easily have handed him a prescription for sleeping pills and left it at that.
Instead — despite the rules and regulations against it — Melino assembled a team of experts to address not just Robert’s insomnia, but also the underlying issues that were affecting his mental health.
A housing worker helped him find a safe apartment. A cardiac specialist and a pharmacist got him the HIV and heart meds he needed. Melino started regular psychiatric counselling visits with Robert to build his trust.
“Robert, like many of my clients, had significant impairment from his mental illness but he was also facing racism, homophobia, living in poverty and conditions of violence,” Melino says.
“The biomedical model of providing prescriptions and sending clients on their way really was not addressing the root cause of what was going on. I started to think there’s got to be a better way to approach their care.”
Melino was determined to conduct research and find the evidence needed to change the health-care system to better meet the needs of complex, vulnerable patients like Robert.
“When you’re on the ground really giving care to people, you can see the gaps,” explains Melino’s co-supervisor Joanne Olson, professor and vice-dean in the Faculty of Nursing. “She sees a system that looks marvellous, it looks glossy and helpful, but when it gets right down to the people it serves, it’s not always meeting their needs.
“Melino’s research is especially important because it fits into that place between the practical and the systematic.”
Which care is “medically necessary”?
A Black gay man from a small town, Robert hadn’t been able to seek specialty treatment for his HIV for more than a decade after diagnosis because he was responsible for raising his four younger siblings. His parents were in jail.
When he finally got to the big city, Robert needed to find a roommate because of the high cost of living. The person he moved in with ended up being a drug dealer, and Robert became hooked on methamphetamine to stay awake all night so no one would rob him while he slept. At age 28, Robert was clinically depressed, struggling with addiction and his heart was failing.
Before he died a year and a half later, he told the team he “had never felt this safe” thanks to the help Melino had organized.
Much of the help given to Robert was deemed “not medically necessary” by the clinic’s accounting department and therefore not billable within the U.S. health-care system, but Melino and team provided it anyway, on their own time when required.
She says they were as creative as they could be in helping him overcome what she calls “structural discrimination.”
“None of that was business as usual. To me it was plain that we can’t keep doing business as usual if we’re actually going to try to make a difference in improving these folks’ lives,” she recalls.
Mapping the “workarounds”
Melino started her university studies with a BA in anthropology from the University of Toronto, where she grew up. Her first job was as a research assistant for the Registered Nurses’ Association of Ontario.
“Through that job I was able to meet so many incredible nurses who had amazing careers and were involved in change and activism and making health care better for patients and nurses,” she recalls. “I just really admired them and I wanted to grow up to be like them.”
She went back for her BScN in nursing at the U of T. After working as a registered nurse for a few years in a Toronto hospital in psychiatric intensive care and on a sexual assault and domestic violence care team, she headed to the University of California at San Francisco to train as a psychiatric mental health nurse practitioner.
After 13 years of practice in both Canada and the United States, Melino decided to pursue further studies. The Faculty of Nursing’s reputation as a top research program led her to the U of A and the nursing PhD program, with Olson and Jude Spiers as her co-supervisors.
Melino used a concept called structural competency to guide her research, a framework that helps health-care professionals identify and address the social determinants of health that affect patients and their mental health — things like racism, poverty, food distribution, even zoning bylaws.
