Identifying the core competencies of mental health telephone triage

Aims and objectives. The primary aim of this study was to identify the core competencies of mental health telephone triage, including key role tasks, skills, knowledge and responsibilities, in which clinicians are required to be competent to perform safe and effective triage. Background. Recent global trends indicate an increased reliance on telephone‐based health services to facilitate access to health care across large populations. The trend towards telephone‐based health services has also extended to mental health settings, evidenced by the growing number of mental health telephone triage services providing 24‐hour access to specialist mental health assessment and treatment. Mental health telephone triage services are critical to the early identification of mental health problems and the provision of timely, appropriate interventions. In spite of the rapid growth in mental health telephone triage and the important role these services play in the assessment and management of mental illness and related risks, there has been very little research investigating this area of practice. Design. An observational design was employed to address the research aims. Methods. Structured observations (using dual wireless headphones) were undertaken on 197 occasions of mental health telephone triage over a three‐month period from January to March 2011. Results. The research identified seven core areas of mental health telephone triage practice in which clinicians are required to be competent in to perform effective mental health telephone triage, including opening the call; performing mental status examination; risk assessment; planning and action; termination of call; referral and reporting; and documentation. Conclusions. The findings of this research contribute to the evidence base for mental health telephone triage by articulating the core competencies for practice. Relevance to clinical practice. The mental health telephone triage competencies identified in this research may be used to define an evidence‐based framework for mental health telephone triage practice that aims to improve the quality, consistency and accuracy of telephone‐based mental health triage assessment.     

Male identity in mental health nursing

AIM: To explore the cultural meaning associated with male mental health nurses. METHOD: An ethnographic approach was used to discover the meaning informants attach to the cultural norms, values and rules that govern their behaviour. Data were collected through participant observation and in-depth interviews with informants. RESULTS: Data were analysed using emerging domains and taxonomies regarding male nurse issues. This involved grouping terms, words and everyday reflections collected from the male mental health nurses. These lists of data (taxonomies) enabled the researcher to identify in-depth cultural themes about the attitudes, behaviours and symbolism typically associated with male nurses. CONCLUSION: A number of cultural themes emerged, including the notion of 'soft masculinity', which provided some insight into male nurses' experiences of working in a female-dominated workplace. A recurring theme was the need for male nurses to demonstrate gentleness and caring while maintaining a balanced sense of masculine identity.     

Mental health triage: towards a model for nursing practice

Mental health triage/duty services play a pivotal role in the current framework for mental health service delivery in Victoria and other states of Australia. Australia is not alone in its increasing reliance on mental health triage as a model of psychiatric service provision; at a global level, there appears to be an emerging trend to utilize mental health triage services staffed by nurses as a cost-effective means of providing mental health care to large populations. At present, nurses comprise the greater proportion of the mental health triage workforce in Victoria and, as such, are performing the majority of point-of-entry mental health assessment across the state. Although mental health triage/duty services have been operational for nearly a decade in some regional healthcare sectors of Victoria, there is little local or international research on the topic, and therefore a paucity of established theory to inform and guide mental health triage practice and professional development. The discussion in this paper draws on the findings and recommendations of PhD research into mental health triage nursing in Victoria, to raise discussion on the need to develop theoretical models to inform and guide nursing practice. The paper concludes by presenting a provisional model for mental health triage nursing practice.     

An educational framework for triage nursing based on gatekeeping, timekeeping and decision-making processes

INTRODUCTION: The role of the triage nurse has emerged in response to growing community demand for a more accessible and efficient emergency department (ED) service. The focus of triage research has been on measuring outcomes and improving the delivery of emergency care. This has meant that the context of care, and triage processes and practices have remained concealed. Thus, little evidence about the role and ways to prepare nurses for this role is available. The aim of this study was to provide insight and understanding needed to educate and support the triage nursing role in Australian EDs. METHODS: A 12-month ethnographic study of triage nursing practice was conducted in Sydney metropolitan EDs. Data were then collected from participant observation in four EDs and interviews with 10 triage nurses. Analysis used standard content and thematic analysis techniques. FINDINGS: Findings reveal that notions of timeliness, efficiency and equity are embedded in a culture of ED care. This sustains a particular cadence of care to which triage nurses are culturally oriented. Triage nurses maintain, negotiate and restore this cadence of emergency care by using gatekeeping, timekeeping and decision-making processes. CONCLUSION: The comprehensive study of triage nursing has led to the development of an educational framework based on the processes of gatekeeping, timekeeping and decision-making.     

Perceptions of crisis care in populations who self‐referred to a telephone‐based mental health triage service

Although psychiatric crises are very common in people with mental illness, little is known about consumer perceptions of mental health crisis care. Given the current emphasis on recovery‐oriented approaches, shared decision‐making, and partnering with consumers in planning and delivering care, this knowledge gap is significant. Since the late 1990s, access to Australian mental health services has been facilitated by 24/7 telephone‐based mental health triage systems, which provide initial psychiatric assessment, referral, support, and advice. A significant proportion of consumers access telephone‐based mental health triage services in a state of crisis, but to date, there has been no published studies that specifically report on consumer perceptions on the quality and effectiveness of the care provided by these services. This article reports on a study that investigated consumer perceptions of accessing telephone‐based mental health triage services. Seventy‐five mental health consumers participated in a telephone interview about their triage service use experience. An eight‐item survey designed to measure the responsiveness of mental health services was used for data collection. The findings reported here focus on the qualitative data produced in the study. Consumer participants shared a range of perspectives on telephone‐based mental health triage that provide invaluable insights into the needs, expectations, and service use experiences of consumers seeking assistance with a mental health problem. Consumer perceptions of crisis care have important implications for practice. Approaches and interventions identified as important to quality care can be used to inform educational and practice initiatives that promote person‐centred, collaborative crisis care.     

Telephone survey of service‐user experiences of a telephone‐based mental health triage service

The participation of service users in all aspects of mental health service delivery including policy development, service planning and evaluation is increasingly an expectation of contemporary mental health care. Although there are a growing number of publications reporting service‐user perspectives in the evaluation of mental health services, little attention has been paid to the views of service users about mental health triage services. The purpose of the study reported here was to examine service‐users' (consumers and informal carers) experiences of a telephone‐based mental health triage service. Using a framework developed from the World Health Organisation's elements of responsiveness, we conducted structured telephone interviews with service users who had contacted a telephone‐based mental health triage service in regional Victoria, Australia. The main findings of the study were that consumers experienced more difficulty than carers in accessing the service and that, although most participants were satisfied, only a minority reported being involved in decision‐making. Further work is needed to improve accessibility of mental health triage services and to investigate barriers to consumer self‐referral. Professional development and practice support systems should be established to support mental health triage nurses in the development of collaborative, consumer‐focused care.     

Investigating the validity and usability of an interactive computer programme for assessing competence in telephone‐based mental health triage

Telephone‐based mental health triage services are frontline health‐care providers that operate 24/7 to facilitate access to psychiatric assessment and intervention for people requiring assistance with a mental health problem. The mental health triage clinical role is complex, and the populations triage serves are typically high risk; yet to date, no evidence‐based methods have been available to assess clinician competence to practice telephone‐based mental health triage. The present study reports the findings of a study that investigated the validity and usability of the Mental Health Triage Competency Assessment Tool, an evidence‐based, interactive computer programme designed to assist clinicians in developing and assessing competence to practice telephone‐based mental health triage.     

Perspectives of collaboration/non-collaboration in a mental health inpatient setting

Research investigating collaboration in health care has mainly taken place in general settings or has focused on the professional viewpoint. The initial aim of this study was an attempt to illuminate and explore 'collaboration' from the perspective of a person with a clinical diagnosis of schizophrenia using a hermeneutic-phenomenological approach. Through in-depth conversation, it became apparent that, rather than describing good examples of collaboration, the participant spontaneously drew attention to episodes of 'non-collaboration' and the difficulties he had experienced in joint decision-making in an inpatient mental health setting. Incorporated are extracts from a reflective journal to reveal the prejudices and preunderstandings of the researcher, who is a mental health nurse. The need for further research encompassing the views of those with a diagnosis of severe and enduring mental illness is underlined.     

Mental health triage in the ER: a qualitative study

RATIONALE, AIMS AND OBJECTIVES: The London Health Sciences Centre found that its emergency room (ER) mental health services were affected by people presenting with problems that did not require psychiatric intervention. Consequently, a second triage using a crisis worker (CW) was introduced in the ER to identify those persons with mental illness (PMI) who presented for social stressors related to housing, finances and legal issues. A qualitative, process evaluation study was conducted to capture experiences and perceptions of the new triage and CW. METHOD: Qualitative input was obtained from a broad range of stakeholders in three waves of data-gathering over a 25-month period. This method allowed corroboration of findings from informants with varying interests and backgrounds. The data were collected through interviews, focus groups and surveys. The NUD-ist Qualitative Data Analysis Software Program was used to conduct content analyses. RESULTS: Many PMI seeking ER mental health services are presenting with problems related to social stressors and being referred by the second triage to the CW. The introduction of the second triage CW has had a positive effect on ER functioning, the workload of ER staff and the experience of persons presenting at ER. CONCLUSIONS: A defined triage process coupled with the use of psychiatric nursing staff may be applicable to ERs within general hospital settings to improve ER functioning, focus support for PMI and further integrate ERs within the community mental health model.     

Measuring the effectiveness of the national Mental Health Triage Scale in an emergency department

ABSTRACT:   The mainstreaming process has significantly altered the means of access to mental health services in Australia. Increasingly people seeking mental health care present at general hospital emergency departments. The triage system, which has proven effective for prioritizing physical illness and injury, has proven problematic when applied to mental health-related problems. This paper presents the results of a study undertaken in the emergency department of a Victorian public hospital. The Mental Health Triage Scale was introduced and used independently by triage nurses and the psychiatric nurse consultants employed in the department. Following a 3-month period, the two sets of triage scores for psychiatric presentations ( n =  137) were compared. The findings suggest that triage nurses are rating clients experiencing mental health problems as in more urgent need of care than their psychiatric nursing counterparts. This suggests that the introduction of the guidelines alone is insufficient, and that education is required for more effective use of the tool.     

Coping with everyday reality: Mental health professionals’ reflections on the care provided in an acute psychiatric ward

There is little research evidence about how the mental health professionals are coping with the complexity of everyday practice in psychiatric acute care. The aim of this study was to explore mental health professionals’ reflections on their work on an acute psychiatric ward. Data were collected using participant observation and interview methods. Three core themes were identified from a qualitative hermeneutic analysis. The first core theme, coping with uncertainty, uncovered a dialectical pattern of the factors contributing to thriving and strain in the working situation. The second core theme, caring for the patient, included the caring process, patients’ pathway to acute psychiatric care, as well as the patients’ needs and roles on the ward. The third core theme, coping strategies, included five different methods the primary nursing system, concealing versus integrating, milieu therapy, seclusion and the medical orientated model. It was concluded that good mental health care is a result of collaboration between health professionals and the health services. This study highlights the need for support to professionals and for establishing structures that will enable collaboration to take place. Taken together, this may contribute to enhancing the care of the patient and their families.     

Recognition as a valued human being: perspectives of mental health service users

The acknowledgement of basic human vulnerability in relationships between mental health service users and professionals working in community-based mental health services (in Norway) was a starting point. The purpose was to explore how users of these services describe and make sense of their meetings with other people. The research is collaborative, with researcher and person with experienced-based knowledge cooperating through the research process. Data is derived from 19 interviews with 11 people who depend on mental health services for assistance at least three times a week. Data is analysed according to the Interpretative Phenomenological Analysis (IPA). Results confirm that reciprocity is fundamental for relationships, and that recognizing the individual entails personal involvement. The participants describe a struggle, and recognizing this struggle may help the professional to achieve a deeper understanding of the individual.     

Should we or shouldn't we? Mental health nurses' views on physical health care of mental health consumers

People diagnosed with a mental illness experience poorer physical health than the general population. Nurses have been identified for their potential role in addressing physical health needs of consumers of mental health services. This paper reports on preliminary findings of a qualitative study on health-care services for physical and mental health in a regional area in Australia. A key purpose of the study was to explore the perceptions of nurses working in mental health settings of their physical care with consumers. A qualitative, exploratory approach was undertaken. Semi-structured focus groups were conducted with 38 nurses from one mental health service. Nurse participants described a common co-occurrence of physical problems and mental illness and expressed the importance of health-care services to treatment and prevention. Participants expressed divergent views on nurses' capacity to contribute to better health-care processes.     

Taking neuroleptic medications as the treatment for schizophrenia: A phenomenological study

Research in the area of neuroleptic medications has traditionally relied on quantitative methodologies which view the problem from the researcher’s perspective. This phenomenological study was undertaken to explore the experience of taking neuroleptic medications from the individual’s perspective using a research approach which has the potential to illuminate and respect participant experiences. Interviews were conducted with 10 individuals who take neuroleptic medications as their main treatment for schizophrenia. Interviews were analysed using an interpretive method which seeks to generate a deeper understanding of the phenomenon under study. The experience of taking neuroleptic medications emerged as incorporating hope for recovery, learning to live with the side‐effects, embodiment of illness, experiencing issues of control, and struggling to stay well. The results have relevance for practicing and novice mental health nurses, for teachers of undergraduate nursing and allied health students, and carer and consumer groups.     

Reducing uncertainty in triaging mental health presentations: Examining triage decision-making

Little is known about how emergency department (ED) nurses make decisions and even less is known about triage nurses’ decision-making. There is compelling motivation to better understand the processes by which triage nurses make decisions, particularly with complex patient populations such as those with frequently emotive mental health and illness issues. While accuracy and reliability of triage decisions generally have been improved through the introduction of standardised triage scales and instruments, other factors such as lack of knowledge or confidence related to mental health issues, past experiences that may elicit transference and countertransference, judgments about individuals based on their behavioural presentations may impact on decisions made at triage. In this paper, we review the current research regarding the effectiveness of triage tools particularly with mental health presentations, present a theoretical framework that may guide research in understanding how triage nurses approach decision-making, and apply that framework to thinking about research in mental health-related triage. Developing a better understanding of how triage nurses make decisions, particularly in situations where issues related to mental health and illness may raise the levels of uncertainty, is crucial to ensure that they have the skills and tools they need to provide the most effective, sensitive, and compassionate care possible.     

Outcomes of referrals over a six-month period to a mental health gateway team

Mental health policy in recent years has prescribed the role, function and form for services in England. Evidence of their effectiveness post-policy implementation has been limited to date and minimal guidance has been available on how services should operate together as whole systems. This paper reports findings from a study of referrals and their outcomes in respect of specialist community mental health services following implementation of national policy and its interpretation and configuration at a local level. Findings highlight that gateway workers configured as a team operating between primary and secondary care can effectively shield community mental health teams from high numbers of referrals that they would deem inappropriate. The study also identified the triage role of this service as being crucial to the effectiveness of developing and maintaining care pathways and also in potentially supporting the mental health capability of primary care.     

Profiling police presentations of mental health consumers to an emergency department

Public mental health systems have been called on to better meet the needs of consumers presenting to health services with the police, yet few studies have examined police presentations among mental health consumers in large public mental health systems. This study was designed to determine the frequency profile and characteristics of consumers of mental health services brought in by police to an emergency department (ED) in Sydney, Australia. Using data from the emergency department information system and obtaining the psychiatric assessment from the medical record, we have examined trends and characteristics in mental health presentations brought in by the police to a general ED between 2003 and 2005. The sample consisted of 542 consumers with a mental health problem brought in by the police to the ED of a 350-bed community hospital. The characteristics of this group were compared with those of all mental health related ED presentations for the same period using logistic regression. Results indicated that police presentations are likely to be young males who are unemployed, have past and present alcohol and other drugs use, present after hours, and are admitted to hospital as a result of their presentation. These consumers are likely to have a presenting problem of a psychotic disorder, less likely to have a presenting problem of depression and/or anxiety, and given a triage code of three or higher. The study results highlight the importance of the availability of 24-hour access to mental health care to ensure a quick care delivery response. Police presentations to EDs with mental health issues are an indicator of significant impact on health services, especially with the current overcrowding of EDs and the associated long waiting times. Systems need to be developed that facilitate collaboration between EDs, hospital security, police services, mental health, and ambulance services.     

Documenting the pre-implementation phase for a multi-site translational research project to test a new model Emergency Department-based mental health nursing care

BackgroundPresentation rates to Emergency Departments (ED) for people with mental health, drug health and behavioural problems are increasing. This necessitates a reorientation of health services and resources to meet this change in demand.AimsThis multi-site translation research project aims to implement and evaluate an innovative model of mental health nursing care in three EDs across New South Wales (NSW) Australia.MethodsThree EDs (one city, regional, and rural site) were selected to participate in the project. A qualitative mixed methods approach was used in the pre-implementation phase comprising clinician focus groups (n = 3) and face-to-face interviews with senior staff (n = 15). A planning day and site visits were conducted involving consultation with key clinical, management and executive staff.FindingsTimeliness of consultations, lengthy assessment and documentation processes and delays in decisions regarding patient disposition were the main frustrations expressed by ED staff and hospital executives. A designated team of mental health nurses based in the ED to see patients from the point of triage was viewed favourably for supporting the therapeutic care of people with mental health, drug health and behavioural problems. However, several psychiatrists raised objections over the clinical governance of the team culminating in one site leaving the project.ConclusionImplementing new models of care that require a change in thinking and practice can challenge power relations which subsequently impact on individual willingness to support proposed change. Therefore, even with demonstrated effectiveness, extensive consultation and high level support the cooperation of key local stakeholders is not always assured.