GP group profiles and involvement in mental health care

Rationale and objectives Mental health is one of the leading causes of morbidity worldwide. Its impact in terms of cost and loss of productivity is considerable. Improving the efficiency of mental health care system has thus been a high priority for decision makers. In the context of current reforms that privilege the reinforcement of primary mental health care and integration of services, this article brings new lights on the role of general practitioners (GPs) in managing mental health, and shared‐care initiatives developed to deal with more complex cases. The study presents a typology of GPs providing mental health care, by identifying clusters of GP profiles associated with the management of patients with common or serious mental disorders (CMD or SMD). Methods GPs in Quebec (n = 398) were surveyed on their practice, and socio‐demographic data were collected. Results Cluster analysis generated five GP profiles, including three that were closely tied to mental health care (labelled, respectively: group practice GPs, traditional pro‐active GPs and collaborative‐minded GPs), and two not very implicated in mental health (named: diversified and low‐implicated GPs, and money‐making GPs). Conclusion The study confirmed the central role played by GPs in the treatment of patients with CMD and their relative lack of involvement in the care of patients with SMD. Study results support current efforts to strengthen collaboration among primary care providers and mental health specialists, reinforce GP training, and favour multi‐modal clinical and collaborative strategies in mental health care.     

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.     

Primary mental health workers in child and adolescent mental health services

BACKGROUND: The interface between primary care and specialist services is increasingly seen as crucial in the effective management of child and adolescent mental health (CAMH) problems. In the United Kingdom, a new role of primary mental health worker (PMHW), has been established in order to achieve effective collaboration across the interface through the provision of clinical care in primary care settings and by improving the skills and confidence of primary care staff. However, little is known about the development of this innovative role in service contexts. Issues raised during the early stages of implementation may have important implications for the preparation and development of professionals who undertake the role. AIMS: The aim of this paper is to report on a study that examined key issues in implementation of the PMHW role in six health authorities in England. METHODS: Case study evaluation was conducted, using thematic analysis of 75 qualitative interviews with key stakeholders from different professions (e.g. PMHWs, general practitioners, health visitors, psychiatrists and service managers) and representing different sectors (primary care, specialist services and community child health services). FINDINGS: The study identified three models of organization (outreach, primary care-based and teams). Each was associated with different advantages and disadvantages in its effects on referral rates to specialist services and the development of effective working relationships with primary care providers. Problems associated with accommodation and effective integration of PMHWs with specialist services, and tensions caused by the two different roles that PMHWs could undertake (direct clinical care vs. consultation-liaison) were common across all sites. CONCLUSIONS: The PMHW role is an important development that may go some way towards realizing the potential of primary care services in CAMH. The implementation of new roles and models of working in primary care is complex, but may be facilitated by effective planning with primary care providers, clear goals for staff, and a long-term perspective on service development.     

Progression of the mental health nurse practitioner role in Australia

The guiding principle of health care is to serve the needs of the public. Healthcare services are therefore required to be increasingly flexible and open to new approaches to meet changing demands. They must also adjust and expand as new challenges are presented. Public awareness of mental health issues and the current demands placed on health services for access to affordable and appropriate mental health care have never been so great. The introduction of nurse practitioners (NPs) in Australia is a proud and long-anticipated moment for the discipline of nursing. However, a major challenge for the introduction of NPs in Australia will be to reassure medical colleagues, allied health professionals and the public that NPs are able to deliver high-quality primary care. This paper elaborates on the progress of the mental health NP role in Australia. Attention is centred on the characteristics the mental health NP role, the maintenance of professional competency to practise at an advanced clinical level, and the prospects and potential significance of NPs for mental health nursing practice. The nurse-led clinic, implemented through the process of consultation and systematic evaluation, is identified as an avenue for the extension of mental health NP practice in the delivery of autonomous primary care.     

General practitioners' views of community mental health services: A survey in one London borough

Community mental health teams are increasingly focusing their activities on people with severe mental illnesses. At the same time, the overall extent of mental health need in primary care ensures general practitioners (GPs) remain key professionals in the co-ordination and provision of mental health services to a wide range of patients. This study sought to establish the views of GPs working in one London borough on community mental health services, and to establish what they believed were appropriate services for community mental health professionals to provide. A postal questionnaire sent to all 104 GPs working in the borough produced a 48% response rate. GPs believed community mental health teams were useful, and effective in dealing with patients presenting with a variety of mental health problems. Many believed that enhanced primary health care teams, adequately resourced and staffed with attached mental health professionals, could provide a wide range of mental health interventions. Dissatisfaction appeared to be related to the evolving focus of community mental health teams. Many GPs believed that they had lost a valuable service for people with less severe mental health needs.     

The challenges of mental health care reform for contemporary mental health nursing practice: delivery of nursing care

This ethnographic account of mental health nursing in a 22-bed acute inpatient facility in New South Wales, Australia, uncovered cultural meaning and cultural realities associated with the delivery of nursing care within the context of current challenges, demands, and influences brought about by service reforms. The findings demonstrate that mental health nurses have been responsive to changes brought about by the reforms. The ability of nurses to readily identify service gaps in their everyday practice provides them with the opportunity to develop strategies to respond to workplace challenges. As such, findings of the study contribute to current discussions concerning acute inpatient mental health nursing practice.     

Teamwork in primary care mental health: a policy analysis

Aim This paper reports a policy analysis conducted to examine the potential impact of recent mental health policy on team working in Primary Care Mental Health in England. Method An analysis of relevant policy documents was conducted. From an original selection of 49 documents, 15, which had significant implications for Primary Care Mental Health Teams, were analysed thematically. Findings There were no clear guidelines or objectives for Primary Care Mental Health Teams evident from the policy analysis. Collaborative working was advocated, yet other elements in the policies were likely to prevent this occurring. There was a lack of clarity concerning the role and function of new professions within Primary Care Mental Health Teams, adding further uncertainty to an already confused situation. Conclusion This uncertainty has the potential to reinforce professional barriers and increase the current difficulties with team working. Implications to nursing managers An analysis of recent policy contributes to our understanding of the context of care. The lack of clarity in current health policy presents a significant challenge for those managing primary care mental health teams. Team working is likely to improve if targets, processes and responsibilities are made clearer.     

Primary care options to prevent mental illness

The common mental disorders, mainly anxiety and depression, constitute a major public health problem, incurring considerable costs in terms of use of health services and time lost from work. Risk factors include low socioeconomic status, poverty and poor housing, as well as stressful life events and difficulties such as demanding child care, separation or divorce, bereavement, loss of employment and caring for a dependant relative. Population approaches are probably necessary to reduce significantly the burden of such mental health problems, but health care measures are far from negligible. Primary care professionals have regular opportunities to identify people at risk of mental health problems and refer them to welfare and social support services (primary prevention). A number of interventions among high-risk groups have been shown to be effective, including problem-solving training and cognitive-behavioural approaches. The most important tasks in primary care are to identify people with depression, alcohol and drug misuse and eating disorders as early as possible in the course of their illness and to institute effective treatment (secondary prevention). Primary care teams should also join in shared care arrangements for patients with chronic disabling mental illnesses, in order to prevent recurrences and relapses (tertiary prevention).     

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.     

Mental health nurse practitioners in Australia: improving access to quality mental health care

Under The Nurses Amendment (Nurse Practitioners) Act 1998, New South Wales became the first state in Australia to legislate for nurse practitioners. Mental health was identified as a priority 'area of practice' for nurse practitioners. Issues surrounding the implementation of the nurse practitioner role in Australia and the potential for the role to address the current crisis in mental health nursing and the mental health sector will be discussed. The potential for partnerships with other health-care providers, in particular medical practitioners, will demonstrate how successful implementation of the role can fulfil consumer demand for primary prevention counselling, improve access to mental health services and early intervention, and provide mental health services that better reflect national priorities. This examination of the Australian context will be contrasted with a review of the overseas literature on mental health nurse practitioners.     

Greek psychiatric care reform: new perspectives and challenges for community mental health nursing

The purpose of this article is twofold: (1) to explore the main issues of psychiatric care reform in Greece and outline the operating way of the new residential structures of psychiatric care and rehabilitation; and (2) to focus on the implementation of mental health nursing roles in the primary care services such as supervisor-therapist, liaison, coordinator-crisis interventionist and counsellor-trainer within the context of a multidisciplinary therapeutic team. Given that multiple professionals are involved in mental health care in primary care, issues of role are likely to be crucial to the effective implementation of new workers. Moreover, there is existing evidence of ambiguity in the roles of different mental health professionals in primary care, relating to the problems they manage and the treatments they provide. The authors believe that more emphasis needs to be given to the mental health nursing specialty in Greece, because the large majority of patients requiring mental health care should have the possibility of taking better quality of care as the psychiatric structures at community are continuously developing.     

Training for transformation: reorientating primary health care nurses for the provision of mental health care in South Africa

Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.     

Enhancing oral health for better mental health: Exploring the views of mental health professionals

The association between oral health, self‐esteem and quality of life is well established yet there is limited research on the impact of addressing the poor oral health of people living with mental health disorders. Greater consideration is warranted on how enhancing oral health in the course of mental healthcare might reduce the burden of a person's ill health. The role of mental health professionals is important in this regard yet uncertainty persists about the role these providers can and should play in promoting oral health care for people with mental health disorders. This qualitative study explored the issue of oral health and mental health with community based mental health professionals in Perth, Western Australia. It examined their views on the oral health status and experiences of their clients, and the different and alternative ways to improve access to care, knowledge and preventative regimens. Findings indicated participants’ ambivalence, reluctance and lack of training in raising oral health issues, despite its acknowledged importance, indicating a siloed approach to care. Findings offer an opportunity to reflect on whether a more integrated approach to oral health care for people with mental health disorders would improve health outcomes.     

A comparison of the work and values of community mental health nurses in two mental health NHS Trusts

With the reconfiguration of health services in both the primary and secondary sectors, the role of community mental health nurses (CMHNs) has become a highly contested one within mental health care. There would be great variability in the skills that CMHNs possess, the contexts in which they work and the nature of the work they do. This study sought to explore aspects of the work of those nurses who provide services at the interface between policy and practice. Two groups of CMHNs were compared, one working in an urban setting (Trust A) and the other in a rural (Trust B), focusing particularly on caseloads and client mix, the values held by CMHNs, the models of care they utilize and what they consider would improve care in the future. A specially designed 39-item questionnaire was employed, with a mix of open and closed questions, and statements to which participants were asked to respond on a three-point Likert scale. The findings raised interesting issues around collaborative working, whether CMHNs are happy to take on clients previously on their caseload, bureaucratization, autonomy, role definition within a culture of working with primary care, lack of specific models utilized by CMHNs, and the demand for greater training and educational support. The implications of the study are discussed with the aim of assisting mental health nurses determine their future roles.     

How can care managers strengthen health literacy among patients with common mental disorders? A qualitative study

Background

In order for persons with mental illness to be able to promote and preserve their health, sufficient knowledge about health is required. An effective means to improve the health of the patients is to strengthen their health literacy. The aim of this study was to explore how care managers work with health literacy in patients with common mental disorders to help them to better understand and manage their illness.

Method

A qualitative study was conducted, using written reports from 25 care managers regarding meetings with patients with common mental disorders in the primary care in a Swedish region. The care managers' reports were coded based on Sörensen's four dimensions for the domain “health care” and analysed deductively through systematic text condensation according to Malterud.

Results

The care managers described how they worked strategically and continuously with follow-up and wanted to be responsive to the patients' stories. They confirmed the patients' feelings with the goal of creating increased interaction, thereby involving the patients in their own care. The care managers also worked actively to provide well-balanced care at an early stage. Using various tools such as self-assessment instruments, the care manager started from the patient's basic problem, gave support and discussed strategies based on the patient's condition and situation.

Conclusions

The care managers used multifaceted health literacy interventions. They worked in a person-centred, strategic and encouraging manner based on the patient's unique conditions, where sensitivity and adapted information were important aspects. The aim of the interventions was for the patients to become knowledgeable, gain new insights and work independently with their own health.     

A role for mental health nursing in the physical health care of consumers with severe mental illness

There is extensive international evidence that people with severe mental illness have a lower standard of physical health than the general population. This leads to higher morbidity and mortality rates. Many of the causes for this poor physical health are modifiable. Yet the physical needs of this consumer group are neglected by healthcare systems in Australia, and elsewhere. While medical specialists are clearly integral to remedying this, nurses are well placed to play a key role in focused prevention and early intervention in the physical well-being of consumers with mental health problems. This paper outlines the specifics on how mental health nurses can be sensitized, prepared and empowered to help turn this serious health issue around. In particular, mental health nurses could be trained in and then utilize a new physical health check and response system in the UK (called the Health Improvement Profile) if adapted for use within Australia. This profile will be briefly introduced, and then its value to improving health care discussed.     

General practitioners' perceptions of community psychiatric nurses in primary care

The management of and responsibility for the care of people with mental health problems in the community is increasingly being assumed by general practitioners (GPs) and primary care personnel. As primary care groups (PCGs) evolve, so must their expertise in managing people with a wide range of mental health problems. It is expected that all mental health professionals will participate in this development, although it is likely that community psychiatric nurses (CPNs) will be the largest professional group involved, with a significant part to play in the shaping, management and delivery of mental health services. To date, there has been little research into how CPNs are perceived by other primary health care professionals. This study seeks to provide an insight into how GPs assess the contribution of CPNs in primary care. Overall, the results of the study suggest that GPs view CPNs favourably and consider that they have an important role to play. Greater involvement in primary care raises issues about the education and preparation of CPNs, their professional development and supervision needs.     

Managed mental health care: problems and possibilities

Case management has become an established organizational approach to mental health care. However, a recent development of case management, known as 'managed care' has received only limited attention in the UK and this has been confined to acute medical or surgical hospital care. The potential of managed care as applied to mental health care is uncertain. This paper clarifies the nature of managed care and discusses its relevance to mental health care, in particular to the care of people suffering from schizophrenia. The high incidence and heavy resource demands of this user group makes these people an ideal focus for managed care. However, there are conceptual and practical problems hindering its development and implementation, including: the variability and unpredictability of the disease process of schizophrenia; challenges of outcome measurement; and problems relating to the current organization of mental health care.     

Models of mental health nurse-general practitioner liaison: promoting continuity of care

AIM AND RATIONALE: Community mental health nurses and general practitioners share a pivotal role in the provision of mental health care in the community. The focus of this study was to identify models of general practitioner collaboration used by these nurses, and analyse the implications of these models for promoting continuity of care. The study was derived from a larger study of how community mental health nurses promote wellness with clients who are experiencing an early episode of psychotic illness. METHODS: This qualitative study used interviews and observation to collect data. The study took place in 1999 in regional and rural New South Wales, Australia and involved community mental health nurses. FINDINGS: The findings show that two models of nurse and general practitioner (GP) collaboration emerged from the data: Shared Care and Specialist Liaison. In the Shared Care model, nurses maintain close contact with GPs throughout the episode of acute care. In the Specialist Liaison model, the community mental health team assumes overall responsibility for care and treatment throughout the acute episode of illness. Contact with GPs throughout the episode of care by the community mental health team is, at best, intermittent. CONCLUSION: The findings suggest that the Shared Care model is more consistent with supporting personal and organizational continuity of care, whereas the Specialist Liaison model is limited to encouraging personal continuity of care but further study is needed.     

The value of community mental health nurses based in primary care teams: 'switching the light on in a cellar'

This paper explores the impact of placing Community Mental Health Nurses (CMHNs) at two primary care practices in South Staffordshire. Data were collected by means of a questionnaire which was sent to primary care personnel at these practices, to ascertain their opinions with respect to the contribution of practice-based CMHNs. Overall, primary care personnel were satisfied with the quality of the service received from the CMHNs, especially in terms of improved communication. They felt that the new arrangements enabled a quicker and more efficient access to the services of the CMHN. The results are discussed in terms of the value of having CMHNs within the primary care setting, and in terms of service planning and future recommendations for mental health services within primary care.