Comparison of integrated and consultation-liaison models for providing mental health care in general practice in New South Wales, Australia

Comparison of integrated and consultation-liaison models for providing mental health care in general practice in New South Wales, Australia The characteristics of a new service providing integrated mental health care in general practice are described and comparisons made with an earlier consultation-liaison (C-L) psychiatry service in general practice, including the range and severity of psychiatric problems, levels of general practitioner (GP) and psychiatrist involvement, and patterns of care. Clinical audit checklists were completed by two experienced mental health nurses for the first 100 patients referred to the service, which was conducted in conjunction with 8 general practices in the Port Stephens region of New South Wales, Australia. The mean age of the first 100 referrals was 38.05 years, 63.0% were female, and 55.0% were referred from GPs. Outcome measures included: referral information, patients' demographic and diagnostic characteristics, psychosocial functioning, psychotropic medication, management, and number of contacts with the mental health nurses. Relative to the earlier C-L psychiatry service in general practice, the integrated service treated a broader range of diagnostic groups with higher levels of disability. There were higher rates of mood (48.0%) and psychotic (20.0%) disorders and lower rates of adjustment (2.0%) disorders. One-third of patients were seen by an additional agency, other than the mental health nurses or GPs. Patients averaged 4.95 contacts with the mental health nurses, with marked variations according to diagnostic group. To date, the new service has been well received. It is highly accessible, acceptable to GPs and patients, caters for a broad range of psychopathology, including severe mental illness, and appears to be sufficiently versatile to be adaptable to a variety of treatment settings.     

The Effectiveness of the Mental Health Nursing Inverventions in a General Hospital

The purpose of the study was to investigate: a) how mental health nursing interventions were provided to general hospital patients, who during their hospitalization presented psychological/pyschiatric problems and b) how the patients actually evaluate the effectiveness of the care given to them. We interviewed 95 medical-surgical patients, who were referred to the psychiatric consultation-liaison service of a general hospital. During the interview, a nursing evaluation of the patients' psychological problems took place, followed by appropriate mental health nursing interventions which were taken from the NOSIE scale and the standards of the Psychiatric Mental Health Nursing Practice. Anxiety was the most common problem 41.1% in the referrals. The comparison of the mean value of the patients' problems before and those after the mental health nursing interventions, showed statistically significant reduction of the problems. Also, the comparison of the mean value in the fourth assessment of the patients' problems with the mean value of the patients' opinion, showed an achievement in facilitating the verbal expression and comforting the physical and psychological symptoms to a point statistically significant.     

Patient satisfaction with psychiatric services provided by a Melbourne tertiary hospital emergency department

The mainstreaming of psychiatric services within the general healthcare system has created fundamental changes to the manner in which patients access acute psychiatric services. This change was intended to reduce the stigma associated with psychiatric diagnosis and therefore contribute to improved treatment outcomes for patients. The aim of this paper is to discuss the results of a study designed to ascertain the level of psychiatric patient satisfaction with the services received in the emergency department of a Melbourne metropolitan hospital. The results indicate a high level of satisfaction, particularly with the availability of staff with psychiatric qualifications and experience to provident treatment, support and care. The major areas of dissatisfaction identified by patients included: lengthy waiting times, lack of privacy in the triage area and negative attitudes of general staff. These findings support the argument from the literature for psychiatric consultancy services to be available in the emergency department, and further identifies the need for triage guidelines to be tailored to the needs of mental health patients and for emergency department triage staff to be appropriately educated to adequately triage these patients.     

The role of a psychiatric consultation liaison nurse in a general hospital: a case study approach.

Growing support for the role of the psychiatric consultation-liaison nurse in assisting general nurses in caring for patients experiencing mental health problems in the general hospital environment is evident from the relevant literature. However, there remains a paucity of research which examines the process of this nursing role or its impact on outcomes for nurses and patients. This paper seeks to contribute to the literature in articulating the role of the psychiatric consultation-liaison nurse using a case study approach to describe the role of the nurse in assessing the needs of, and, planning and providing care to two general hospital patients experiencing mental health problems, and the general nurses caring for them.     

Asylum blues: staff attitudes towards psychiatric nursing in Sarawak, East Malaysia

This paper draws upon findings from an ethnographic study of psychiatric service users in a psychiatric institution in Sarawak, East Malaysia. Findings focus primarily on the accounts of nursing staff in relation to attitudes towards psychiatric work and patients. These indicate that despite a rhetoric of decentralized services, a custodial 'asylum' model continues to influence the care of patients at many levels. Negative professional attitudes towards patients lead to issues of both moral and physical containment. However, an associated attitude of stigma and prejudice towards mental illness impacts upon how attractive a career in psychiatric nursing is perceived to be by respondents, subject to gender differentials.     

How effective are mental health nurses in A&E departments?

Background

A&E departments are key points of contact for many people with mental health problems. Various models of care have been developed in A&E departments for delivering mental health services, but few have been assessed for effectiveness. The present study aimed to assess the impact of a dedicated A&E psychiatric nurse service on several outcomes relevant to patients and clinicians.

Methods

A crossover design was used to introduce a dedicated psychiatric nurse service (comprising four experienced community psychiatric nurses) into two busy UK A&E departments. Standardised assessments were completed for each patient, and a random sample of these independently assessed for quality. Data were also collected on the number of patients assessed, psychiatric nurse time employed, waiting times, onward referrals, repeat attendances, patient satisfaction, and staff views.

Results

A&E staff referred about a third of patients judged to have mental health problems to the psychiatric nurse service; approximately half of those assessed had a psychiatric history. On average, assessments took 60 min and over 90% of the formulated management plans were judged appropriate by independent assessors. The psychiatric nurse intervention had little impact on waiting times or satisfaction levels for mental health patients, although there was evidence of a change in onward referral patterns.

Comment

Psychiatric nurse assessment services have been introduced in many A&E departments, although the evidence base for the effectiveness of this development is not well established. This study presents evidence that psychiatric nurses can provide an accurate assessment and referral service with advantages for patient care.     

Exploring therapeutic engagement with individuals with a diagnosis of personality disorder in acute psychiatric inpatient settings: A nursing team perspective

Individuals with a diagnosis of personality disorder (PD) face negative attitudes and are often deemed harder to care for than individuals with other diagnoses. To improve care and engagement with services, it is essential to understand the ways general psychiatric nursing staff approach this client group. This research aims to examine the ways inpatient psychiatric nursing staff therapeutically engage with individuals with a diagnosis of PD. Focus groups were conducted with Registered Mental Health Nurses (n = 7) and Health Care Assistants (formally known as nursing assistants; n = 12) who care for individuals with a diagnosis of PD in a general psychiatric inpatient setting. A thematic analysis indicated six themes: the right frame of mind, knowing the service user, knowing when to engage, service user input, a unified approach, and structured admissions. The findings highlight what non‐PD specialist inpatient nursing staff do in order to engage therapeutically with this group of service users and areas that require improvement. Supporting good practice could improve staff confidence when caring for this client group, lower stigma around the diagnosis, and promote a more positive experience of care for individuals with a diagnosis of PD who are using general inpatient mental health services.     

If You Could Change 1 Thing to Improve the Quality of Emergency Care for Deliberate Self-harm Patients,What Would It Be? A National Survey of Nursing Leadership

IntroductionEmergency departments increasingly treat patients for deliberate self-harm. This study sought to understand emergency department nursing leadership perspectives on how to improve the quality of emergency care for these patients.MethodsED nursing managers and directors from a national sample of 476 hospitals responded to an open-ended question asking for the 1 thing they would change to improve the quality of care for self-harm patients who present in their emergency departments. We identified and coded key themes for improving the emergency management of these patients, then examined the distribution of these themes and differences by hospital characteristics, including urbanicity, patient volume, and teaching status.ResultsFive themes regarding how to improve care for deliberate self-harm patients were identified: greater access to hospital mental health staff or treatment (26.4%); better access to community-based services and resources (26.4%); more inpatient psychiatric beds readily accessible (20.9%); separate safe spaces in the emergency department (18.6%); and dedicated staff coverage (7.8%). Endorsement of findings did not differ based on hospital characteristics.DiscussionED nursing leadership strongly endorsed the need for greater access to both hospital- and community-based mental health treatment resources for deliberate self-harm patients. Additional ED staff and training, along with greater continuity among systems of care in the community, would further improve the quality of emergency care for these patients. Broad policies that address the scarcity of mental health services should also be considered to provide comprehensive care for this high-risk patient population.Key wordsEmergency department management of self-harm; Mental health care; Emergency nursing care     

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.     

The need for psychiatric nursing: towards a multidimensional theory of caring

Contemporary developments in health care have encouraged a review of the professional status of psychiatric nursing. Although research has documented psychiatric nursing activity, little study has been made of the 'need' for psychiatric nursing within a multidisciplinary service. Employing adapted grounded theory methodology, substantive theory was developed concerning the expressed need for psychiatric nursing, by patients, their carers and mental health professionals. The study was based on six sites from England, Eire and Northern Ireland. The study found some consensus across both recipients and providers of mental health care, that the essential feature of nursing (the core category) involved a complex of relationships: 'knowing you, knowing me'. Within that complex, nurses either elected, or were required, to move--or 'toggle'--between three discrete domains of relating: the Ordinary Me (OM); the Pseudo-ordinary or Engineered Me (POEM); and the Professional Me (PM). Four internal dimensions involving the nurses' depth of knowing, power, use of time and use of translation distinguished these domains. The emergent theory extends current awareness of the importance of interpersonal relations in nursing. To what extent current health care policy, which emphasizes the promotion of alternative roles for nurses, will challenge this essential focus remains unclear.     

The mental health nurse: contributing to improved outcomes for patients in the emergency department.

Fundamental changes to health-care policy in Australia have led to an increase in the extent to which emergency department staff come into contact with patients experiencing mental health problems. This has been problematic for nurses, many of whom perceive themselves as lacking the skills and expertise to provide appropriate care and treatment to this client group. Psychiatric/mental health consultation-liaison nursing within the emergency department is becoming established as a means to overcome some of the problems identified. Despite this growth there is a paucity of literature evaluating the effectiveness of this position. This paper presents the results of an evaluation of the mental-health consultation-liaison nurse role in an inner city teaching hospital in Sydney Australia. The survey involved a three stage approach to data collection. The data collected at the commencement of the position included focus groups to ascertain the needs of emergency department nurses and a questionnaire designed to measure the skills, confidence and perceived knowledge of emergency department nursing and medical staff. An evaluation of the satisfaction of nurses and doctors was conducted towards the end of the three month pilot programme. The results confirmed the need for positions of this type and suggested a high level of satisfaction with the service provided.     

The required role of the psychiatric-mental health nurse in primary health-care: an augmented Delphi study

An augmented Delphi study was employed to elicit the perceptions of CPNs, GPs, social workers, managers of psychiatric nursing services and health service purchasers in England, on the role required of a psychiatric (mental health) nurse in primary health care. In the final stage of the study, users of mental health service were enlisted in a verification study of the emergent findings. A broad consensus emerged that a gap existed in mental health services in primary care. This was perceived as placing a large burden on GPs, which might be reduced by the appropriate development of community psychiatric-mental health nursing. The study suggested the possibilities for development of a 'mental health nurse consultant' role, which might augment the current CPN role, within which the nurse might offer not only direct patient care, but also support to members of the primary care team.     

An overview of the role and functions of a psychiatric consultation liaison nurse: an Australian perspective

The role of the psychiatric consultation liaison nurse (PCLN) has increased substantially in popularity over the last few years. Despite the growth of this position, a paucity of literature regarding the role, functions and effectiveness of psychiatric consultation liaison nursing continues to exist. The current study was undertaken as part of the Victorian Nurse Practitioner Project. A significant aspect of this study concerned collection of data on the activities of the PCLN. This approach enabled an extensive and detailed profile of the PCLN to be formulated. The findings indicate that the PCLN provided a service to nursing, medicine and allied health in relation to patients experiencing mental health problems in the general hospital setting. Patients referred to the PCLN presented varied clinical features in terms of medical, surgical and mental health disorders. The PCLN performed a range of interventions. The results of this study make a significant contribution to address the current paucity of literature.     

Nursing care in a combined adolescent medical-psychiatric unit.

In spite of the problems we have encountered in combining adolescent medical and psychiatric patients, we have found this to be a workable model. In summary, several areas are important in making this model functional: staff interest in both medical and psychiatric patients, in-service programs particularly in psychiatry, and open communication between health care givers. Certainly one of the most positive aspects of this unit is that it provides an environment which allows for easier adjustment to the community after hospitalization. Avoidance of such terms as "mental hospital," "crazy person" is less traumatic to the adolescent patient and his family.     

Developing and testing methods for improving patient-oriented mental health care

There is a trend in nursing policy and practice towards allowing patients to participate actively in their treatment and the services they use. The author concludes, based on an earlier qualitative study, that psychiatric patients in a hospital environment want a more active role in their treatment and that psychiatric nurses also aim at more active patient participation. In mental health care, professionals often define the needs of patients in terms of their own expertise and tend to overlook the variety of the service users' needs. The need to improve and empower psychiatric patients is a considerable challenge to present-day nursing. The purpose of this paper is to describe the theoretical background of tools used to assess patients' involvement in mental health care and the process by which credibility can be determined in rating the panel phase of instrument construction. The instruments, based on a qualitative study using grounded theory, produced a model of patient initiatives in psychiatric nursing. Content validity refers to the determination of the substantive representativeness or relevance of the items of an instrument. Face validity has been defined as validity conferred by a lay persons' acceptance that a procedure, statement or instrument appears to be sound or relevant. In the panel rating, the raters were experts. They evaluated the readability, consistency and content validity of the instruments' items. In the instrument for nurses, the content validity was 0.84 and consistency 0.91; this corresponds to 0.91 and 0.95, respectively, in the instrument for patients.     

Training in cognitive behavioural interventions on acute psychiatric inpatient wards

There has been a drive towards addressing the types of care and therapeutic interventions available to people with serious mental illness, which is reflected in the latest government mental health policy initiatives. Recent evidence strongly supports the implementation of psychological and social interventions for people with psychosis, and in particular the use of cognitive behavioural techniques. Until now, the main focus has been on people living in the community. This study examines the delivery of psychosocial interventions training to qualified psychiatric nurses and unqualified staff on seven acute psychiatric admission wards in London, UK. The approach had the strength of on-site delivery, follow-up role modelling of the interventions and clinical supervision. Despite this, in some cases the training was less successful, mainly because of staffing and leadership weaknesses. The impact of training in these methods and the implications for mental health education and practice development are discussed.     

Treatment regimes in a psychiatric hospital and apparent contradictions: Report from field work in a lock‐up ward illustrated with a constructed case

The medical approach dominates in Norwegian psychiatry, but mental health nurses and other ward staff hold that milieu therapy constitutes an additional and important treatment approach for psychiatric patients. In this study, we wanted to explore these approaches as they are implemented in inpatient treatment. We conducted a 9‐month ethnographic study in two lock‐up psychiatric wards in a Norwegian psychiatric hospital. In this article, we present a constructed case, Mary, to illustrate the voices, experiences, and perspectives of patients and staff as observed primarily in the patients' smoking room, the corridor, and the staffroom. From the perspective of staff, we identified at least two professional perspectives concerning patients' daily life: a strong medical–psychiatric view and a weaker therapeutic milieu, which seemed difficult to implement. When considering the view of people in care, we observed that patients' experiences and points of view occurred and remained to a large degree in their smoking room, and patients seemed to have little impact on their own treatment programmes. This stands in sharp contrast to patients' legal rights to participate in any important decisions regarding their treatment and to the espoused person‐centred orientation in health care today.     

Implementing child-focused family nursing into routine adult psychiatric practice: hindering factors evaluated by nurses

Aims and objectives. The aim of this study is to describe nurses’ evaluations of factors that are hindering implementation of child‐focused family nursing (CF‐FN) into adult psychiatric practice. In addition, it explains the nurses’ evaluations of the hindering factors related to the hospital organizational structure, the individual nurse, nursing and family. Background. There is an increasing amount of families with dependent children in adult psychiatry. Although these families have long‐term benefits from preventive family interventions, implementation of CF‐FN is not routine mental health practice. Design and methods. Data were collected via a questionnaire‐survey completed by Registered Psychiatric Nurses (n = 223) and practical Mental Health Nurses (n = 88) from 45 adult psychiatric units in five Finnish university hospitals. The response rate was 51%. Results. Family‐related factors, such as families’ fears and lack of time, were considered as ‘most hindering’ to CF‐FN. Nurses who used a family‐centred approach and had further family education considered most of the factors as ‘less hindering’ in comparison to other nurses. Conclusion. To meet the needs of the families in mental health services, it is essential to develop nursing intervention methods such as CF‐FN. There is a need for further education and use of family‐centred care to develop this preventive approach. Relevance to clinical practice. The results of this study could be considered when developing mental health services and family interventions for families with parental mental illness.     

The effect of organizational climate on the clinical care of patients with mental health problems.

INTRODUCTION: During the past 3 decades, the number of patients with serious mental health problems seeking care in general hospital emergency departments has increased exponentially, with special clinical challenges. This study examines the effect of organizational climate--the subjective perceptions of staff regarding the work environment--on ED staff members' attitudes toward patients with mental health problems, as well as the effect on the clinical care of these patients. METHODS: The data for this study came from a written survey of 109 emergency nurses and other clinical staff employed in a general public hospital emergency department in a midwestern city (response rate = 67.9%). RESULTS: The findings indicate that the emergency nurses and other clinical staff who view their working conditions positively report having more frequent contact and providing a greater variety of interventions to patients with psychiatric problems. Staff members who believed that their clinical work roles and expectations are poorly defined were those least likely to interact with this patient population. DISCUSSION: The findings indicate that organizational processes seem to have an impact on the delivery of clinical care, as well as caregivers' attitudes about this patient population. This finding underlines the importance of addressing organizational climate in emergency departments as part of an effort to improve the quality of care for patients with mental health problems.