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Evaluating an education project in mental health of older people

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To enhance the delivery of appropriate care to older people with mental health problems, and to ensure carers and service users are well informed, The National Service Framework for Older People (Department of Health, 2001) and the Audit Commission (2000) advocate that mental health services develop training to support staff working with older people in the primary and secondary care sectors.


VOL: 100, ISSUE: 35, PAGE NO: 38

Rose Butler, BSc, RMN, is nurse educator in older people’s mental health services, Local Health Partnerships NHS Trust, West Suffolk

To enhance the delivery of appropriate care to older people with mental health problems, and to ensure carers and service users are well informed, The National Service Framework for Older People (Department of Health, 2001) and the Audit Commission (2000) advocate that mental health services develop training to support staff working with older people in the primary and secondary care sectors.



To meet this recommendation the Local Health Partnership Trust, together with West Suffolk Hospitals NHS Trust, commissioned a project and put in a bid for funding. The work also meets the requirements of The NHS Plan (DoH, 2000).



The project
The remit was to develop an education and training pathway for improving the knowledge and skills of non-specialist NHS-registered and support staff working at West Suffolk Hospitals in the assessment, care and treatment of older people with identified mental health problems. This would enable staff to:



- Assess patients;



- Form care plans;



- Carry out planned care;



- Support patients.



These skills are important because nurses play a crucial role in assessing patients, and offer a fundamental, holistic perspective on meeting individual, family and community needs (UKCC, 1997).



The nurse educator was to deliver the training packages, evaluate them on a sessional basis and evaluate the project when it concluded, generating recommendations from the results.



To keep the size of the workload manageable within the agreed budget and time constraints, the project focused on 105 ward nurses and allied health professionals at Walnut Tree Hospital in Sudbury, Suffolk.



Key learning outcomes and success criteria were developed (Box 1) in order to satisfy health care professionals’ requirement to improve their knowledge, develop their skills and sometimes change their attitudes, as described by Wattis and Curran (2001).



Developing the workshops
Networking enabled the nurse educator to explore, and compare and contrast, other projects and initiatives.



The subjects to be covered were researched from a variety of sources, not only to give the workshops a depth of evidence/research-based information, but also to ensure the information was current and credible in line with the requirements set out by the Modernisation Agency (2004).



Two tutors from Suffolk College of Health offered to support the project by examining the content before the workshops were held. This was carried out to ensure content was up to date, current and credible.



Line managers - the older people’s mental health services (OPMHS) service manager and the OPMHS clinical team leader in the locality - supervised the project.



The nurse educator carried out an assessment of educational need via primary data from:



- Meetings with ward and day hospital managers (sisters/charge nurses) who could identify their own and their staff’s educational needs through staff professional development processes/appraisals;



- Staff needs assessment questionnaire;



- User and carer questionnaire.



The privacy and dignity section of Essence of Care (DoH, 2001) was used to develop the questionnaires.



Staff needs assessment questionnaire



The assessment questionnaire for staff revealed that the majority (70 per cent) wanted to know about distraction techniques, while more than half (59 per cent) wanted to find out about managing difficult behaviour. Almost all staff wanted more information on coping after a difficult situation (98 per cent) and medication for older patients (90 per cent). In addition, there was an overwhelming ‘yes’ response (98 per cent) to wanting to know more about communication with older patients who are perceived to have mental health problems.



Although staff thought they knew about the symptoms of depression (92 per cent) and dementia (90 per cent), there were clear gaps in their knowledge revealed by responses to some of the questions.



Two-fifths of staff (40 per cent) said they did not feel comfortable working with patients who have mental health problems.



Carer and patient satisfaction



A total of six questionnaires were completed - two by patients and four by carers. The patients’ comments indicated that they:



- Were unaware they had a care plan;



- Were unaware of staff asking for information to enable a care plan to be written;



- Found it hard to find a member of staff to talk to;



- Did not have enough activities, and although they asked staff for things to do were told there were not enough staff to help in getting things out;



- Enjoyed the experience of being in hospital overall because of the good food and company.



The carers’ comments showed a similar lack of awareness, revealing that:



- They were not aware of being involved in the care-planning process;



- They were not aware if they were asked for information to enable a care plan to be written;



- They were not approached to give information that would have enabled the patient to settle on the ward;



- The patients’ personal routines were not explored, which made the experience less pleasant for them as their routines were not allowed to continue;



- There were upsets to routines around mealtimes and bedtimes, and watching TV was a problem;



- Finding a quiet area was a problem;



- Staff attitudes were not always helpful as they were too busy with other things, and patients needed to fit in with the staff routine;



- They were not kept informed of any issues or changes and had to ask staff for information;



- The level of privacy was poor.



The learning packages
After collating all the data, the nurse educator was able to identify the learning needs of the target group and then develop the necessary educational packages on the following topics:



- Communication;



- Depression;



- Dementia;



- Challenging behaviours.



Method of delivery



The workshops were based on adult learning - pedagogy as described by Quinn (2000) comprising self-directed learning, further reading and reflective practice homework. Learning was applied to practice, and evidence of this was provided in the homework.



Emotional intelligence - described by Evans and Allen (2002) as including the ability to manage your own emotions and read someone else’s at the same time, and to use this to guide your thinking and actions - was incorporated into the workshops. This was to give staff greater self-awareness in order to enable them to have more effective interactions with patients and to help them deal emotionally with highly charged situations.



Communication was the first workshop as the nurse educator thought this was the most important aspect of working with any patient. Understanding how to communicate effectively can prevent problems throughout the patient journey. Communication was also a central theme throughout the other three workshops.



To evaluate the effectiveness of the workshops, attendees were asked to carry out a piece of reflective homework that would also help them to put learning into practice on the wards. In addition, 77 evaluation questionnaires were given out. The response rate was 96 per cent (74 replies were received).



Johns’ Model of Structured Reflection (1995) was used for the reflective practice homework, and of the 77 given out only 10 were returned (a response rate of 13 per cent). Lastly, 99 non-attendee questionnaires were sent out and seven of these were returned (a response rate of seven per cent).






The evaluation questionnaires indicated that 79 per cent of attendees felt the workshops were either ‘good’ or ‘very good’ (Fig 1).



The reflective practice homework that was returned was regarded as a positive response to the programme, as it helped the facilitator to evaluate whether learning was being put into practice. The work required staff to identify a patient to work with as a case study and to find time to carry out this extra work.



These studies were confidential and therefore are not reported here. However, the overwhelming finding was that staff had incorporated the learning into their practice and were applying person-centred care.



The non-attendee questionnaires gave lack of time due to staff shortages as the reason for not attending and confirmed a desire to attend had they been able.



Despite in-session evaluation being very positive, attendance remained low, with only 46 out of 105 staff attending (44 per cent of those invited to attend). Overall there were 77 attendances owing to some people attending more than one workshop.



According to Wattis and Curran (2001), workshop models of teaching are generally preferred, and attitudes are changed by exposure to people with different attitudes in favourable circumstances. This is supported by Nightingale (2004), who states that the success of long-term mental health awareness-raising initiatives shows that a prolonged approach is essential if entrenched attitudes are to change.



After consultation with senior sisters and ward/unit managers, the sessions were held at staff handover time to enable as many staff as possible to attend. The questionnaires did not ask for staff to state their grade, but the information that had been volunteered indicated that most attendees were unregistered nursing staff.



Although this level of uptake was disappointing, the nurse educator concluded that learning outcomes had been met and that an increase in skills and knowledge about older people’s mental health had been achieved. The nurse-educator believed person-centred care was being applied according to the reflective practice homework that had been submitted.



The workshops were successful because learning outcomes appear to have been achieved. On reflection there are a number of conclusions to be drawn from the project, including ideas that would benefit the project and that would have made a difference (Box 2).






To ensure the work of the project is not wasted, and to support research showing it is vital that training is sustained (Nightingale, 2004), the workshop packs need to be:



- Incorporated into an induction pack for new staff;



- Part of a postregistration training pathway, in a similar way to those for nutrition and continence;



- Mandatory training for qualified/unqualified staff;



- Incorporated into an NVQ package, and preregistration nurse training;



- Offered to local residential/nursing homes for staff;



- Offered to social services staff;



- Offered to primary care teams.



Senior staff need to be engaged and accept the need for training. However, it takes time to implement change, to get staff interested and motivated, and to establish new ways of working and thinking.



- This article has been double-blind peer-reviewed.

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