A staff questionnaire at a psychiatric nursing home analysed how the development of a multi-professional group benefited staff and patients
Gianetta Rands, MRCGP, FRCPsych, MA, is consultant psychiatrist; Margaret Ford, RMN, RM, RGN, is team manager; Abosede Okeowo, RMN, is team leader; Celia Matthew-Bernard, RMN, RM, RGN, is team leader; Joceline Kapfumvuti, RMN, is senior staff nurse; Annette Skinner, RMN, is senior staff nurse; all at Camden and Islington Foundation Trust.
Rands, G. et al (2009) How consultation liaison meetings improved staff knowledge, communication and care. Nursing Times; 105: 42, early online publication.
This article describes the evolution of a multi-professional group in a psychiatric nursing home for older people with mental illness and challenging behaviours. The nursing home has gained a reputation for excellence, and we believe the group has contributed to this.
To analyse how the group has helped, a staff survey was carried out. As a result, we suggest that groups like this should be a standard part of community liaison services for residential homes for older people.
Keywords: Mental health, Nursing home, Multi-professional work, Staff education
This article has been double-blind peer reviewed
Devoting one hour a month to attend a consultation liaison meeting developed:
- A shared vision that focused on individualised patient care and better patient management;
- Support for each other between meetings, and effective multi-professional working;
- Increased knowledge about mental illness, skills to manage challenging behaviours and medication;
- Improved confidence and collaboration across the team, and better communication;
- Increased involvement of relatives and carers through regular evening meetings.
Although for many years good practice in mental health and care of older people has emphasised the importance of communication between service providers, there is little literature specifically about community liaison with care homes. Despite this, there is a current trend for primary care trusts to recruit nurses to liaise with registered care homes, and their jobs are evolving in a number of ways (McAllister and Matarasso, 2007).
Caring for older people with mental illness is a highly multi-skilled task and all too often the expertise needed is under-resourced and lacks multi-professional support.
While our group was set up about four years ago, it fulfils several of the recent dementia strategy objectives (Department of Health, 2009). These are:
- Objective 5 - development of structured peer support and learning networks;
- Objective 11 - living well with dementia in care homes;
- Objective 12 - improved end-of-life care for people with dementia;
- Objective 13- an informed and effective workforce for people with dementia.
Aim of the survey
Here we describe holding multi-professional consultation liaison meetings in a psychiatric nursing home for older people. These meetings were extremely effective, so a staff questionnaire was designed to analyse which components make them successful.
The home provides psychiatric nursing care for up to 30 older people with severe mental illness and behaviour problems. For 2009 it has a Care Quality Commission “excellent” rating (three stars), the provider type is “voluntary”.
Within a year of starting the consultation liaison meetings, the nursing home gained a reputation for being able to manage challenging behaviours and the problems of the most severely disturbed older people in the borough, who could not be managed in other community settings.
The home has three units, each with 10 residents. They have single rooms and communal dining and sitting spaces. There is an enclosed garden on the ground floor. Residents are placed at the home after comprehensive multi-professional assessments of their needs and consideration by the borough care home placements panels. The home’s philosophy is to provide holistic care in a “home from home” setting.
The Care Programme Approach (Box 1) is used so that each resident receives care specific to their needs and preferences.
Visiting times are unrestricted and staff actively encourage residents’ relatives, friends and carers to join in the home’s day- to-day activities and to participate in care planning and review meetings.
Box 1. Summary of the Care Programme Approach
The Care Programme Approach (CPA) is used in the UK to describe the framework that supports and coordinates effective mental health care for people with severe illness in acute mental health services.
The government introduced it in 1990, updated it in 1999 and published positive practice guidance last year (DH, 2008), which made changes to the CPA that became effective from October 2008. Now, two levels of support and coordination are currently determined:
- Standard support for people receiving care from one agency, who are able to self manage their mental health problems and maintain contact with services;
- Enhanced support for people with multiple care needs from a range of agencies, likely to be at higher risk and disengaged from services.
CPA consists of four elements:
- Care plan;
- Care coordinator;
The care home is owned by the borough PCT, managed by a housing association and staffed by the local mental health trust. Staff are mainly registered mental nurses (RMNs), nurses with both mental health and general qualifications and care assistants. There are at least two RMNs on duty on every shift.
Other mental health professionals visit on a peripatetic or as needed basis, as do a podiatrist, dietitian, physiotherapist, speech and language therapist, dentist and district nurses. The home-linked GP visits regularly every week for routine reviews and as required for emergencies. Out-of-hours emergencies are covered by the local GP co-operative.
The consultation liaison meeting
The meetings came about because the care home was experiencing a number of difficulties managing residents with challenging behaviours and new, unexplained symptoms. Residents’ needs and their degree of mental illness had become increasingly complex since the home opened 15 years ago as part of the local “asylum” re-provision. Referrals were being made to the local community mental health teams on a weekly basis and residents were having frequent hospital admissions.
The care home manager discussed the situation with both the link GP and the community psychiatrist, who decided to meet together to consider how to help staff provide the best quality care for residents and make optimum use of local health resources.
The meetings took place at the home every three months and lasted for about three hours. The format rapidly evolved into a large meeting attended by 10-12 care home staff and their manager. The link GP and liaison psychiatrist attended all the meetings.
A typical meeting
The meetings usually started with general discussion about the care home, any recent staff or resident changes, local changes in health and social service provisions and any ”political” concerns, such as commissioning intentions.
The agenda would then be reviewed to prioritise new residents, any visitors and any major concerns staff had. The three units decided the order for discussion depending on which staff needed to leave early, but generally all attending staff stayed throughout, with up to 16 cases being discussed per meeting.
Cases were presented by unit staff, whose preparation included: a description of current concerns; a review of the resident’s notes, detailing their history and diagnoses; a recording of current measurements, such as blood pressure, pulse, weight, blood sugar levels; and presentation of current medication charts. A recent mental state examination would have been done by the unit staff, as well as a cognitive assessment if appropriate. Details of family, visitors, outings, interests and habits were included.
The main concerns were considered and refined by extensive discussion and sharing theoretical and practical knowledge. Management options included further assessment or investigation (often by the GP or psychiatrist), further identification of the problem, for instance by using a behaviour chart (such as A-B-C chart – Antecedents, Behaviour, Consequences) and consideration of management options.
Nursing staff had a number of skilled techniques for managing difficult behaviour and often they would choose these before opting for a trial of a psychotropic medication. It was always our aim to use as little medication as possible because of the risks of side effects and drug interactions, which are particularly common in older patients.
Sometimes several options would be agreed in a priority order, so there would be plenty to try before the next meeting in three months’ time. One option might be to phone the psychiatrist and request a short admission for further assessment of a particular resident if other strategies were not working. Knowing this option existed was reassuring for staff, who rapidly developed the “Yes it’s difficult but we can do it” attitude to managing these residents with such complex needs.
We all learnt from discussing these options and could share our experience, knowledge and any recent research we had found in different journals. Interventions made at previous meetings were also reviewed.
After the meetings individual patients were seen if needed and the discussions were summarised by one of the doctors.
After a brief introduction five questions were presented with ample space for answers.
Eleven care home staff completed questionnaires and all responses were very detailed. Themes from their replies are outlined here (Table 1 summarises the main gains seen in these replies).
Question 1: what are the three main things you have learnt from the joint meetings?
- Increased ability to manage difficult situations holistically to consider family, financial and social issues, and to use new skills (8/11 replies);
- Multi-professional work and good communication (9/11) – roles of different professionals; realising importance of nurses in community care; learning from each other; support and direction from medical staff; feeling supported by each other; communicating well with each other; increasing each member’s confidence to manage difficult situations; time for reflection;
- Increased knowledge (6/11) – particularly about recognising signs and symptoms of mental illness, about preventative measures and when medication might help in managing residents’ distress.
Question 2: what changes have you noticed in your approach to managing patients following the meetings?
- Improved knowledge to manage “difficult” residents better, such as: holistic, and therefore more accurate observation; understand mental states better; individualise care; provide best care; improved skills to manage, monitor and care; managing on a day-to-day basis; with support from multidisciplinary team (MDT);
- Guidelines and strategies: understand them better; incorporate guidelines and strategies into nursing care more effectively;
- Improved self reflection and understanding own behaviour and approach to patients: “It has encouraged me to reflect on my own behaviour, and my approach and to normalise myself and my clients’ behaviour”; “My approach became more simple and flexible”; more positive approach.
Question 3: have the meetings resulted in any changes in the way you have organised your service? If so, please describe these.
All 11 respondents said the meetings had resulted in changes. Examples included:
- Keeping residents at care home rather than referring to hospital for investigations and medication changes;
- Learnt new strategies for managing residents;
- Changed attitude about when to refer to hospital;
- Good referral system means good early intervention and involvement of families for individualised care;
- Preparation of cases in advance of meetings focuses on individual patients and their problems;
- Learning about how MDTs work and decision making;
- Learning opportunity for support workers;
- Learnt holistic approach;
- Systematic definition of tasks;
- Psychiatrist involved in care plans and advises on changes to residents’ medication;
- Reflection on each nursing intervention that helped to improve care.
Question 4: what do you think have been the most important contributions from the meetings?
- Updates in care and high quality care for residents;
- MDT views and networking;
- Opportunityto voice concerns and be heard;
- Able to offer quality service to staff;
- Help to treat each client as an individual;
- Improved communication within MDT and GP;
- Increased awareness and understanding of issues;
- Case discussion;
- Good relationships with GP and psychiatrist;
- Exchange of ideas;
- Advice and direction;
- Holistic care.
Question 5: any other comments about these meetings?
Staff valued the meetings as teaching sessions, for discussion and for improving care. Quotes from this section included:
- “Staff at care home look forward to these meetings and feel they have benefited from the discussion”;
- “These meetings are important and essential for the high standard and quality of care that is given in the home”;
- “Able to meet as a multi-professional team to discuss, plan and implement the best care possible for the individual residents who would otherwise not have received this intervention”.
Summary of the impact
The meetings seem to have contributed to uniting and motivating staff to provide the best possible care to residents, to take pride in their work, and to respect each others’ knowledge and skills.
Staff enjoyed their new reputation for being able to manage the borough’s most challenging older patients, who often seemed to settle and enjoy improved quality of life after transfer to this home.
A shared vision evolved throughout the meetings that focused on individualised care, taking a longitudinal view of each resident – including their family, social context and preferences about end-of-life care. Staff confidence in their skills and strategies to manage difficult situations increased.
Staff were able to support and help each other between meetings and were confident that if they contacted the GP or psychiatrist for help a discussion would follow and rapid action be taken.
The link GP commented: “From a GP perspective this regular meeting was hugely supportive. The staff were very well prepared… and there was a real collaboration in planning care. My understanding of dealing with this group of clients has benefited hugely, as did my confidence in dealing with issues that arose between the three-monthly meetings.”
Relative support meetings were initiated and took place every three months, usually in the evenings. All relatives and carers were invited and the meetings were well attended. Topics discussed included mental capacity and decision making, end-of-life care, resuscitation, daily activities and outings and any queries raised by relatives. They often commented they were pleased to hear that a psychiatrist visited and that “patients were being looked after properly”.
We all devoted one hour per month (a three-hour meeting every three months) to these meetings and the benefit to both team members and patients seems to have been enormous. The meetings stopped due to a change in the consultant psychiatrist’s job plan from November 2008, but due to protests from nursing home staff this work will be reinstated from November 2009.
We recommend that consultation liaison meetings like this one should be considered as a key component of community liaison services.
Table 1. Main gains referred to by staff in questionnaire replies
Main gains and selected comments
|Better management of patients|
About the following topics:
|Effective multi-professional work|
- There is a current trend to recruit nurses to liaise with registered care homes.
- The dementia strategy (DH, 2009) emphasises the importance of developing skills and provisions in this area.
- Multidisciplinary teamwork has been shown to have significant benefits for both staff and patients.
We would like to thank the following colleagues for their contributions to this group:Vilma Toledo, Elizabeth Poku-Addai, Dananjay Hurree, Collen Ogbebor, Sally Tambie, Ruth Lanogwa, Owodunni Osinuga, Paul Quinn, Lorna Cole and Dr Patrick McDaid.
Department of Health (2009) Living Well with Dementia: a National Dementia Strategy. London: DH.
Department of Health (2008) Refocusing the Care Programme Approach: Policy and Positive Practice Guidance. London: DH.
McAllister, M., Matarasso, B. (2007) Mental health community liaison in aged care: A service of value to all. International Journal of OlderPeople Nursing; 2: 2, 148-154.