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INNOVATION

Integrating mental and physical healthcare

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Registered adult and mental health nurses participated in a job rotation programme so they could meet the physical and mental healthcare needs of patients

Abstract

Mental and physical health are interconnected, so it is important that nurses feel confident when caring for patients with either type of ill health. Nurse training in the UK means that often those who focus on physical health have little professional exposure to people with mental ill health and vice versa. This can leave nurses feeling hesitant about dealing with people who have illnesses for which they have not been trained. With this in mind, a trust developed a job rotation programme so nurses could rotate between mental and physical healthcare. This article outlines the details of the programme and preliminary feedback.

Citation: Chesnaye P, Philip Kemp (2016) Integrating mental and physical healthcare. Nursing Times; 112: 32/33/34, 20-23.

Authors: Paul Chesnaye is a practice facilitator/rotational nurse lead at Goodmayes Hospital, Ilford; Philip Kemp is visiting lecturer, London South Bank University.

Introduction 

Over the years, researchers have found considerable evidence of a significant interrelationship between mental and physical health (Happell et al, 2013). People with serious mental illnesses or common mental health disorders are at a greater risk of a range of medical conditions compared with the general population (Naylor et al, 2012; Haddad et al, 2010; Haddad 2009; Mykletun et al 2009; Brown et al, 2000).

Approximately three-quarters of premature deaths of people with serious mental illness are caused by physical illness, with cardiovascular disease being the most common cause (Brown et al, 2000). Similarly, long-term physical conditions can have a negative result on mental health, with evidence that this situation affects over four million people in England alone (Naylor et al, 2012).

The government strategy No Health Without Mental Health (Department of Health, 2011) signalled a major re-focusing on the interrelation between mental and physical healthcare. For example, in mental health nursing the introduction of physical health checks has become an important focus of patient care.

With respect to mental health, a “care gap” has been found, whereby the physical healthcare needs of people with a mental illness are not effectively met by primary or secondary mental health services (Edward et al, 2012; Jordan et al, 2000). A recent report on the care of older people, in particular, suggests such a care gap also runs in the opposite direction (Parliamentary and Health Service Ombudsman, 2011).

Moreover, not all staff feel confident about addressing patients’ mental health needs in a physical health environment (Brinn, 2000). While some adult-trained nurses have expressed fear and powerlessness, and acknowledged that these patients require more time than others (Gillette et al, 1996), some nurses have questioned whether it is part of their role (Reed and Fitzgerald, 2005). Lester et al (2005) also suggested that health professionals perceive mental healthcare of people with serious mental illness as too specialised for routine primary care because they lacked sufficient skills and knowledge.

Gaps in nurse education

Concerns about nurses’ ability to approach healthcare holistically have inevitably raised questions about  nurse education in the UK – in particular, the four specialist pathways of adult, mental health, children’s and learning disability nursing. In contrast to the generic education programmes more common in other countries, the UK approach to nurse education has been likened to training nurses in silos, indicating that once trained they are the “finished article” (Willis, 2015).

In recent years, the issue of specialist pathways has been explored in depth in the three-year consultation undertaken by the Nursing and Midwifery Council (2010), the review undertaken by the Prime Minister’s Commission on the Future of Nursing and Midwifery in England (2010) and the Willis Commission (2012). Willis (2015), in a subsequent review, stated that “the current four-strand pre-registration training route has served us well but has continued to marginalise mental health”, but also said that he “would like to encourage a wider debate to see if greater parity between mental health and physical health can be achieved.” Due to such concerns about the ability of nurses and other health professionals to integrate mental and physical healthcare,  it is perhaps unreasonable to expect nurses to provide holistic  healthcare  in a safe, professional and confident manner within their practice. Service enhancements and further reforms of nurse education are a few ways to help remedy the situation.   

Rotational programme for nurses

Taking the initiative to help bridge this apparent care gap, the North East London Foundation Trust (NELFT) has designed an 18-month pilot rotational project for nurses. The project aims to meet workforce development needs by focusing specifically on the trust’s newly-qualified nurses.

NELFT is one of the UK’s biggest NHS providers, providing comprehensive mental health and community services in the London boroughs of Barking and Dagenham, Havering, Redbridge and Waltham Forest, as well as community healthcare services in parts of Essex and children’s mental health services across Essex. This range of responsibilities has highlighted the importance of nurses from all specialties being able to provide integrated mental and physical healthcare. The First Destination Rotational Nursing project is an initiative through which newly-qualified nursing staff from both mental health and adult fields follow a common 18-month developmental rotational programme. The objective is to improve their ability to use holistic nursing skills and thus enhance the quality of care of, initially, older adult patients, regardless of whether their primary health issue is mental or physical.

As a major provider of inpatient and community care for both mental health and physical health, it is important for NELFT that its nursing staff can provide holistic nursing. The First Destination Rotational Nursing Project aims to:

  • Address and explore the changing environment of healthcare provision;
  • Examine the current traditional roles;
  • Address professional differences that have been described as tribalism (Beattie, 1995).

The project is being evaluated using an action research methodology.

Scoping survey

To define the project’s scope, a local survey of 30 final-placement student nurses from the adult nursing field was initially conducted. Of these, 25 felt they had not had enough exposure to mental health service users; 29 stated that a mental health placement would be very beneficial and 18 felt they would have concerns about nursing people with mental health issues as they had not had enough training in mental illness nor mental health issues (Fig 1, attached).

Although the sample size was small, the results were consistent with the concerns outlined above, whereby adult health student nurses recognised a “care gap” in their competencies at the point of registration. Likewise, Nash (2005) showed where registered mental health nurses were involved in delivering physical healthcare, 96% believed they needed more training.  

One final-placement student surveyed used a four-week elective placement to gain insight into a mental health environment. When asked about the experience the student said: “A four-week placement is insufficient to fully appreciate all of the complexities involved in caring for people with mental health issues but, overall this experience was very beneficial to my nursing practice and something that should be incorporated into the education programme for adult nurses. It has provided me with a greater insight into the conditions experienced by those suffering from poor mental health.”

Features of the project

The pilot rotational programme began with three band 5 nurses recruited in October 2014. Newly-qualified adult and mental health nurses recruited to the project will undergo further post-qualifying training together. This is consistent with the Department of Health’s (DH) aim that there should be more opportunities for different health professions to share learning and more emphasis on non-clinical aspects of care, such as communication skills (DH, 2001a; 2001b).

It incorporates established six-month preceptorship requirements (NMC, 2006). In line with DH (2010) guidance, the preceptorship period is spent in the practitioners’ qualifying field to build confidence and carry out  the role for which they are employed. The nurses are also allocated a clinical supervisor, as recommended by Whitehead (2009), who said: “A clinical supervisor should be available full time to support and give guidance to newly qualified[s] whilst on shift.”

The preceptorship programme has been specifically adapted so  rotational nurses can incorporate the education required for older adult nursing, which includes mental and physical health challenges and competencies. On completion of the preceptorship, all nurses on rotational placement embark on four three-month supported educational experiences, coupled with a related tailored education package. Each participant is allocated a mentor/supervisor who will support and supervise his or her learning throughout each experience. The placements will provide opportunities for:

  • Adult nurses to develop essential skills and gain the experience required for nursing older adults with mental health conditions;
  • Mental health nurses to gain essential skills around older adults with physical health conditions.    

Participants begin visiting their placement settings two weeks before they start, to familiarise themselves with the area and team. They also continue to work in their own initial practice area to maintain their current skill sets. While nurses can develop holistic nursing skills without completing a rotation, a registered mental health nurse said that by participating in this project she was “gaining a real insight to the person as a whole.” A registered adult nurse supported this, adding: “I now see the value of communicating, and spending time with your patient.”  

Preliminary evaluation

Formal evaluation

The pilot will be evaluated using action research (McNiff, 2002; Winter and Munn-Giddings, 2001). McNiff (2002) stated this methodology is a form of research closely linked to practice and has been referred to as “practitioner-based research”. Its cyclical nature – whereby one phase of data collection and evaluation informs subsequent developmental changes and analysis – is seen to fit well with the project aims and helps formulate and evaluate practice innovations. The key elements of the approach include:

  • Use of reflective journals (Phelps, 2005): these record nurses’ experience of rotation. Lamb (2013) describes the research journal/diary as a means to communicate feelings and opinions to make them what Ortlipp (2008) described as “visible”;
  • Pre-arranged action learning sets: nurses will attend these throughout the pilot, facilitated by the project lead. As well as being a key source of evaluation data, the sets will act as a source of shared learning from experience that informs developmental changes and offers participants systematic support;
  • Support for all supervisors: this will be provided where experiences and best practice can be shared and recorded.   

Knowledge acquisition will also be assessed by end-of-placement testing (Fig 2, attached). The learning competencies and assessment tasks will be set by a group of “legitimate knowers” (McNiff, 2002) – staff (one per nurse per rotation) with expertise in the placement areas.

Participating nurses will have individual competency objectives in place before they start each rotation. They will also be tested against peers who are not on the programme at the end of each rotation; a final test will take place at the end of the programme. The tests will potentially shed light on participants’ experiences and how the training influences their perceptions, skills and knowledge base about holistic nursing care of older adults. This will inform the wider implementation of the approach when the pilot has been completed.

Preliminary evaluation

Preliminary evaluation indicates that the participating nurses are now better equipped to support the teams in which they work. Importantly, it has created an interest in senior staff to rotate between mental and physical health environments. Rotational nurses have reported feeling more confident working in adult and mental health ward settings and in leading shifts. Box 1 gives quotations highlighting the benefits of the programme.

The early findings are corroborated by ward managers and other staff involved in the rotation. Early test results suggest rotational nurses perform better than their peers when asked both physical health and mental health questions. However, these are early indicators only as the testing is, at the time of writing, incomplete. The final report and results will be completed in November 2016.

Box 1. Participants’ feedback

“It’s only now that the rotation has finished and I am working with other [registered adult nurses] I am noticing the differences in my practice and the need to highlight to colleagues the need to focus on a patient’s mental and physical health equally.” (Adult nurse)

Being exposed to both fields of nursing during the rotation, meant I was able to go back to either an adult or mental health environment and transfer my newly acquired skills to nurse holistically (which has now become second nature when I practice).

As a mental health nurse I was always an ambassador for my patient’s mental health: now as a rotational nurse, I advocate for a patients physical AND mental health.

I was also able to teach those in the adult nursing teams about mental health and share my knowledge, allowing for opportunities for other adult nurses to start recognising their patient’s mental health thus enabling a holistic approach. (Mental Health Rotational Nurse 1)

“I am better able to understand the language of physical health illness since completing the rotational nursing role, which is invaluable when communicating with multidisciplinary teams, especially medical clinicians and when highlighting concerns of a physical health illness or potential life threatening situations.”

“Completing the rotational nursing role supports my future practice in continually learning, developing and growing as a holistic practitioner.”

“I see my role as being one of a holistic practitioner, whereby I am able to have insight into a patient’s physical health, as well as their mental health”.

“I feel in undertaking the rotational role, I have been able to change some staff member’s beliefs and understanding of our patient’s mental health, and how an adult nurse approaches and supports the mental health of our patients in multidisciplinary teams”. (Mental Health Nurse 2)

Both registered mental health nurses also said they supported this in their own areas and added that they have felt like ambassadors for mental health when working in physical healthcare environments and also the same for physical health upon their return to mental health environments.

“Having a rotational nurse made us more aware of the importance of addressing our patients’ mental health needs.” (Senior district nurse)

Conclusion

It is anticipated that this initiative will highlight and inform what practical experience and education must include to provide newly-qualified nurses with the skills to effectively meet older adults’  mental and physical nursing care needs in a safe and competent manner. The competencies for the nurses participating in the project are being developed and, in line with an action research approach, will evolve as the nurses undertake each rotation. By the end of the rotations, it is hoped that this study will produce a set of competencies that newly-qualified mental health and adult nurses will be able to work towards ensuring they have the relevant skills to nurse older adult patients holistically and with more confidence.

In a climate of budget restrictions, this might appear a costly way of addressing the issues raised, and other healthcare organisations might have difficulty duplicating the programme. However, to improve the quality of care in an area of practice that has been resistant to change, these costs may have to be accepted if the model produces convincing outcomes.

While the intention is to roll out the final model trust-wide, this aim may change in the light of NHS budgetary pressures. A more-modest innovation could still draw on the insights arising from the pilot evaluation – for example, current and future participants could be strategically placed within to act as facilitators, developers and catalysts who translate the learnings developed into practice.

Key points

  • It is vital that individuals maintain both good mental and physical health
  • Physical and mental health have an effect on each other
  • Nurses often feel confident caring for people with either physical or mental ill health, but not both
  • Rotational programmes can allow mental health nurses to undertake a placement in physical healthcare settings and vice versa
  • Exposing nurses to a field in which they do not usually work can help them improve the care they provide
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