An emergency department-based mental health nurse practitioner outpatient service: part 1, participant evaluation

The mental health liaison nurse role in the emergency department (ED) has demonstrated a range of positive outcomes for both consumers and staff. In Australia, the added value associated with establishing mental health nurse practitioner (MHNP) positions based on this model is emerging. This paper presents qualitative findings from a study using a mixed-method design to evaluate an ED-based MHNP outpatient service in Sydney, Australia. In evaluating this new service, semistructured interviews were conducted with a random selection of study participants and a stratified sample of ED staff. This is the first of a two-part paper that presents an analysis of qualitative data from interviews conducted with study participants (n = 23). Participants reported numerous therapeutic benefits from the service, such as support, understanding, and a focus on solutions rather than problems, and high levels of satisfaction with the accessibility of the service and follow up. Suggestions for improving the service were also offered. Participants emphasized that overall ED service provision would be enhanced through additional resources, especially an extension of operating hours. Findings from these participant interviews provide strong support for an ED-based MHNP outpatient service.     

Refining the model for an emergency department-based mental health nurse practitioner outpatient service

Refining the model for an emergency department-based mental health nurse practitioner outpatient service
The mental health nurse practitioner (MHNP) role based in the emergency department (ED) has emerged in response to an increase in mental health-related presentations and subsequent concerns over waiting times, co-ordination of care and therapeutic intervention. The MHNP role also provides scope for the delivery of specialised primary care. Nursing authors are reporting on nurse-led outpatient clinics as a method of healthcare delivery that allows for enhanced access to health-care, particularly following hospital discharge. However, due to a lack of in-depth substantiation, this mode of service delivery requires more thorough investigation. This study describes the refinement phase undertaken before the implementation and pilot evaluation of a formalised and structured MHNP outpatient service in the ED of a large inner-city hospital in Sydney, Australia. An expert advisory panel (EAP) consisting of key local informants was convened to provide feedback on and refinement to the proposed model. This related to issues such as target population, structure and process considerations, outcome measures and interface within the overall health service. Findings from the EAP meeting are presented and discussed. The importance of linking methods with the appropriate methodology in evaluating a healthcare program is highlighted.     

Exploring the scope of the Emergency Department mental health nurse practitioner role

The mental health nurse practitioner (MHNP) role in the Emergency Department is focused on assessing and intervening to assist people in mental distress. The skills and expertise associated with this role are also compatible with the provision of short-term outpatient care. This scoping study investigated the potential for a MHNP outpatient service for patients presenting through the Emergency Department with a range of undifferentiated mental health concerns. The specific aim of this study was to explore the feasibility, structure, and potential outcome measures that may be used to evaluate a MHNP outpatient service. Data for the study were gathered via an extensive literature review and two separate focus group interviews. A series of semistructured interviews conducted with key informants were also undertaken to incorporate a range of clinical, academic, health manager, consumer, and carer perspectives. Findings from the study including prospective benefits and barriers associated with the implementation of this new service are highlighted and discussed. These findings indicate that a structured and formalized MHNP outpatient service has the potential to address a current deficit in the health-care system by providing timely, accessible, primary prevention, and early intervention mental health care that better meets the needs of the public and is consistent with the Australian National Mental Health Plan (2003-2008). A MHNP outpatient service also provides an important opportunity to explore, expand, and more clearly define the unique and valuable contribution of advanced mental health nursing practice to contemporary health care.     

Evaluating a new model of nurse-led emergency department mental health care in Australia; perspectives of key informants

BackgroundMental health nurse services have existed in Emergency Departments (ED) for many years. However, there is considerable variation in the way these services operate, and no standardised model of care has been articulated.AimTo evaluate an extended hours nurse practitioner-led mental health liaison nurse (MHLN) service based in an ED in Sydney Australia.MethodsAs part of a larger mixed-methods study, semi-structured interviews were conducted with a sample of ED patients and nursing, medical and psychiatry staff (N = 46). Newly recruited MHLNs were interviewed at the commencement and conclusion of the study period. This paper presents the qualitative component from the evaluation.ResultsThe new service was met with high levels of approval by patients and staff. MHLN team members were challenged by their new role but considered the service reduced waiting times, provided therapeutic benefits, and enhanced communication and support for emergency staff.ConclusionA nurse practitioner-led extended hours MHLN service embedded within the ED team structure provides prompt and effective access to specialised mental health care for people with ‘undifferentiated health problems’ and removes a significant workload from nursing and medical staff.     

Mental health liaison nursing in the emergency department: on-site expertise and enhanced coordination of care.

OBJECTIVE: To evaluate the Mental Health Liaison Nurse (MHLN) service based in the emergency department (ED) of a large, inner city teaching hospital in Sydney, Australia. DESIGN: Data were gathered over the first two years of the position. Information is presented regarding the length of time that patients waited to be seen by the MHLN. Results from two rounds of surveys conducted with ED nursing and medical staff are tabulated. RESULTS: Data obtained from the Emergency Department Information System (EDIS) demonstrates that the Mental Health Nurse Practitioner (MHNP) is able to see a majority of patients at, or close to, the point of triage. These findings are reinforced by ED staff who rate highly the readily available access to mental health assessment and enhanced coordination of care. The strong clinical focus of the role is acknowledged by the ED staff who perceive that patients are better supported therapeutically and spend less time waiting in the department due to MHLN intervention. CONCLUSIONS: This evaluation suggests that the MHLN role has significant benefit for patients presenting to the ED by reducing waiting times, streamlining transition through the department and improving follow-up. The MHLN is highly regarded by the staff as an on-site source of clinical expertise. The information obtained supports the established model and will be used to guide the direction of the service.     

The role of the nurse practitioner in psychiatric/mental health nursing: exploring consumer satisfaction

There is a substantial body of literature pertaining to the role of the nurse practitioner. Research directed towards consumer satisfaction suggests that the care provided by nurse practitioners is perceived as at least equal to that provided by a medical practitioner. However, there is a paucity of literature examining the nurse practitioner role in the psychiatric/mental health field. An evaluation of a Nurse Practitioner demonstration model has recently been undertaken in the Crisis, Assessment and Treatment Team in Victoria, Australia. This article presents the findings of a qualitative, exploratory study. Individual interviews were conducted with consumers (n = 7) who had received care and treatment provided by the nurse practitioner candidate. Data analysis revealed two main themes: the quality of the service provided, and the unique role of the nurse. The findings supported the available literature in articulating the specific aspects of the nurse practitioner role that are favourably perceived by consumers of services. This study contributes to the limited body of knowledge in the psychiatric/mental health nursing field and specifically emphasizes the importance of the relationship between nurse practitioner and consumer in facilitating the provision of effective care and treatment.     

The mental health nurse practitioner in the emergency department: an Australian experience

This paper describes the establishment of a mental health nurse practitioner (MHNP) position in New South Wales, Australia. The authors report on a MHNP role that functions collaboratively within a large inner city emergency department. Attention is centred on what constitutes advanced mental health nursing practice in the emergency department setting. Three areas associated with the work of MHNPs--therapeutic techniques, prescribing and care coordination and referral--are highlighted to explore the scope of the MHNP role. The authors propose that the success of this position is based on a process of consultation and evaluation, partnership between disciplines and clinical services and the role maintaining a truly nursing focus rather than attempting to replace or replicate psychiatric medicine.     

Introducing a new model of emergency department-based mental health care

This article highlights the importance of the three-phase process used to develop and implement an emergency department-based, mental health nurse practitioner (MHNP) outpatient service in a teaching hospital in Sydney. Australia. The project included a feasibility study and a model refinement phase followed by implementation and pilot evaluation. Support for the initiative was secured through early engagement with relevant stakeholders, from exploring the potential for the proposal through to pilot evaluation. Preliminary findings from the pilot study are presented. The authors propose that the project succeeded by emphasising a nursing model of practice.     

Integrating Nurse Practitioner–Led Mental Health Care in Emergency Departments

Responding to the growing number of people presenting to emergency departments (EDs) with mental health, substance use, and behavioral concerns is a significant clinical challenge. Traditionally, EDs have relied on segregated and in-reach models, usually funded by mental health services and focused primarily on providing EDs with “mental health assessments.” This is no longer adequate for facilitating prompt therapeutic care, reducing ED length of stay, and supporting ED staff. This brief report summarizes key findings from a multisite study conducted in New South Wales, Australia, implementing and evaluating a nurse practitioner–led mental health liaison nurse service based in the ED.     

An evaluation of a community aged care nurse practitioner service

Evaluation aims. An evaluation is presented that aimed to augment current understandings of the nurse practitioner role by investigating potential outcomes of a community aged care nurse practitioner (ACNP) service on clients and the health care team. Background. In Australia, the nurse practitioner role is being implemented in a variety of health care settings and is characterized by extended practice: prescribing of medications, requests for diagnostic investigations, referral to medical specialists and admitting clients to inpatient facilities. Design. An exploratory qualitative evaluation method through data collection by interview and thematic analysis was undertaken. Method. All clients referred to the ACNP service between June and August 2003, and a convenience sample of health professionals, were invited to participate in individual semi‐structured interviews. Results. Findings suggested that an ACNP could provide a high quality of holistic nursing care and positively affect clients’ physical and psychological symptom management, enhance clients’ quality of life, assist with supplies, provide health education and assist with advocacy. Health professionals commented on effective collaboration with the ACNP service during their partnerships in client care provision. Conclusions. Overall, the positive effects of the ACNP service on clients and the health care team support the full implementation of the role within the community setting. Relevance to clinical practice. Funding support for the nurse practitioner role is a vital addition to consideration in the development of international policy on advanced practice nursing. Without adequate funding, the full benefits of the nurse practitioner role in clinical practice, as suggested by the findings presented in this evaluation, will be compromised.     

Emergency department mental health triage consultancy service: a qualitative evaluation

This study evaluated staff perception of a three-month clinical trial of an emergency mental health triage and consultancy service. Eleven night duty emergency department (ED) staff were interviewed on the last night of the trial. Data was analysed according to the standards of qualitative research and through content analysis major themes were identified. Staff-perceived value of the emergency mental health triage and consultancy service to the emergency department was identified under three major themes: "enhancing the quality of service for people requiring psychiatric/psychosocial intervention", "the impact on the ED environment" and "providing education and support". The findings of this study show that ED staff perceived that the emergency mental health triage and consultancy service made a valuable contribution to the overall functioning of the ED. The findings also highlight the advanced practice role undertaken by mental health nurses in the ED.     

The nurse practitioner in primary care: alleviating problems of access?

Improving access to primary care services is an essential component of the NHS modernization plan and the advent of independent nurse practitioners in primary care has focused attention on the extent to which this group of nurses can effectively substitute for GPs. This study was designed to explore the role of a nurse practitioner in primary care, particularly whether the provision of a nurse practitioner facilitated access to care that met the needs of patients. Semistructured interviews were conducted with 14 patients who had consulted with the nurse practitioner, 10 staff within the practice who had knowledge of the role, and the nurse practitioner herself. With the permission of interviewees, interviews were audiotaped, the tapes transcribed verbatim, and the data were coded by theme. It was perceived by both groups of interviewees that access to care had been improved in that there were more appointments available, appointments were longer than they had been previously and were available at different times of the day. However, some areas in which access was 'restricted' were articulated by staff interviewees, such as limitations to the nurse practitioner's prescribing and problems with referring patients to secondary care. Additionally, while access to a member of the primary healthcare team was improved for many patients, access to a specific member of the team, such as a GP, was not always improved. Concerns were also expressed about how the role of the nurse practitioner needed to be developed in the practice. It can be concluded from this study that, potentially, the role of nurse practitioner has much to offer in terms of addressing problems of access in primary care for some patients. However, this is not a straightforward solution and in order for the role to be effective several issues highlighted in this study require addressing.     

Applying a realist(ic) framework to the evaluation of a new model of emergency department based mental health nursing practice

WAND T, WHITE K and PATCHING J. Nursing Inquiry 2010; 17 : 231–239
Applying a realist(ic) framework to the evaluation of a new model of emergency department based mental health nursing practice Evaluation has become progressively popular within public health and healthcare programme research, with an emphasis on outcomes and a desire to improve practice and service delivery. Mixed methods approaches are consequently being employed to capture the multidimensional characteristics of programmes that aim to address problematic situations affecting targeted populations. This paper provides an overview of critical realism, a modern philosophical perspective that seeks contextualised causal understandings of social phenomena. Realistic evaluation, a research methodology adapted from critical realism, is highlighted as a means of obtaining a deeper appreciation of how complex programmes work, for whom they work, and under what circumstances. The evaluation of a mental health nurse practitioner outpatient service based in the emergency department of a large teaching hospital in Sydney Australia is used to illustrate the application of a realist perspective to research in nursing practice.     

Patient Education in the Emergency Department

The emergency department (ED) visit provides an opportunity for patient education. Many ED patients have poor access to regular health care, including patient education. Accreditation standards, legal considerations, and cost-efficiency concerns encourage the clinician to implement formal patient education in the ED. More importantly, published clinical studies evaluating patient education in both the ED and comparable settings support the hypothesis that ED-based patient education improves outcomes. The article discusses considerations for instructional material, highlights challenges to ED-based patient education, and suggests possibilities for future research.     

Patients’ and healthcare professionals’ experiences and perceptions of physiotherapy services in the emergency department: a qualitative systematic review

Background

Worldwide, emergency department (ED) attendances and admissions to acute care have increased significantly. Many EDs are adding physiotherapists to their team thereby allowing doctors to see more cases that are ‘urgent’. This is a move away from the ‘traditional’ physiotherapy service whereby the ED team refers patients to an outpatient physiotherapy service sometimes resulting in significant delays. Internationally, there is no agreed consensus on the role or value of ED-based physiotherapists.

Aim

The objective of this review was to retrieve, critically appraise and synthesise the evidence from studies relating to patients’ and healthcare professionals’ experiences and/or perceptions of physiotherapy services in the ED.

Method

This is a systematic review (SR) synthesising qualitative studies, which have considered patients’ (population 1) and healthcare professionals’ (population 2) experiences and/or perceptions (outcomes) of ED physiotherapy services (exposure). A comprehensive systematic search, limited to English language articles, was undertaken on seven electronic medical databases (Medline, EMBASE, CINAHL, AMED, BNI, PubMed and PEDro) for the period January 2006 to October 2016. Grey literature was identified using Google Scholar, reference lists and website searching. The Critical Appraisal Skills Programme (CASP) qualitative checklist was used to appraise all included studies. All studies were data extracted and quality appraised by two reviewers to enhance rigour and reduce bias.

Results

A total of 2163 studies were screened, 10 received full-text review and 7 studies were included in the final review. Six of the studies originated in Australia and one from the USA. The themes that emerged were as follows:

• Patients and healthcare professionals view ED-based physiotherapists as having (1) expert clinical skills and (2) an educational role.
• There is role confusion and lack of integration of the ED-based physiotherapist within the ED team.

Conclusion

This review adds an in-depth human perspective to the current ED physiotherapy literature, which provides insight into how ED healthcare services and physiotherapy services specifically should be developed and delivered in the future. The knowledge from this review has implications for future education programmes, as well as development of both new care pathways and physiotherapy clinical roles.Research into ED-based physiotherapy services is predominantly quantitative. Despite the newness of the ED physiotherapy role, this review reveals that the provision of physiotherapists within EDs contributes value to both patients and staff. However, the dominance of Australian research means it is uncertain how it translates to the UK or elsewhere. There needs to be further UK-based research.

     

Emergency nurses’ perceptions of the health care system and how it impacts provision of care to people who self-harm

BackgroundSelf-harm is a deliberate act to cause physical harm to oneself. People who self-harm are at greater risk for suicide than people who do not self-harm. Emergency nurses are first responders to many people who present to the emergency department (ED) with self-harm. The care they provide can influence future presentations to the emergency department and long-term outcomes.AimThe aim was to explore ED nurses’ experiences of working with people who self-harm.MethodsSemi-structured interviews were conducted with 18 emergency nurses from different locations in Australia in 2019. Elo and Kyngäs’ inductive content analysis research method guided all stages of the research.ResultsThe category “health care system” emerged from the data. It comprised five subcategories: (i) Complexity of the work environment; (ii) ED staff attitudes and care provision; (iii) the mental health patient; (iv) facilitators and barriers to providing care to people who self-harm; and (v) lack of community resources.DiscussionThis study found there were several factors influencing ED nurses’ knowledge, skills and confidence in caring for people who self-harm and several factors influenced their experience.ConclusionWhile participants felt confident to manage the physical injuries associated with self-harm, they were less confident to engage with the person about their self-harm. The article provides guidance for ED nurses to assess and intervene with people who present with self-harm.     

Statewide Mapping of Nurse Practitioner Models of Practice Throughout Victoria

As nurse practitioner (NP) numbers increase, diversity and location of practice varies. This exploratory, prospective, observational, cross-sectional multicenter study was conducted to determine diversity and location of NPs in Victoria, Australia. An online survey about NP workplace and models was sent to 339 NPs throughout Victoria. Forty health services employed ≥1 NPs. Of those working in hospital settings, most were inpatient settings in a metropolitan hospital. Most NPs had a prescriber number, and less than half had a Medicare provider number. We identified heterogeneity in NP models with gaps in service provision in community and mental health.