VOL: 98, ISSUE: 16, PAGE NO: 42
Michael Nash, MSc, BSc, RMN, is a senior lecturer in mental health, University of North LondonMichael Nash, MSc, BSc, RMN, is a senior lecturer in mental health, University of North London
The National Service Framework for Mental Health (Department of Health, 2000) sets out seven standards for planning and delivering mental health services in the UK.
Standard two concerns the effective delivery of high-quality services in the primary care setting for people with common mental health problems. People with severe mental illnesses will have their needs met under shared-care arrangements with local mental health trusts. The standard states that any service user who contacts their primary health care team with a common mental health problem should have their mental health needs identified and assessed, and should be offered effective treatments including referral to secondary mental health services if required.
To achieve these aims, the primary care workforce will need the necessary skills to conduct mental health care assessments and deliver the appropriate intervention. However, at present it seems that trust human resources departments and education providers are on a blind date, both too shy to make the first move. Joint workforce planning involving all local stakeholders needs to be more proactive so that appropriate training is identified and provided, enabling primary care staff to meet the needs of mental health service users.
Is primary mental health care important?
Primary care is usually the first point of contact for people experiencing mental health difficulties. One in four people in the UK is estimated to have some form of mental illness (Royal College of Psychiatrists, 2000), with more than 90% of this client group managed in primary care (Goldberg and Huxley, 1992). Consequently, the skills necessary for assessment, prevention and early intervention should be taught not only to support practitioners but also to achieve policy implementation. However, mental health education, as well as service provision, has frequently been regarded as the Cinderella branch of health care (Lewis, 2001).
The role of training needs analysis
The Audit Commission (2001) states: 'Education, training and development of health care staff in NHS trusts is key to meeting patients' needs, improving the quality of care, supporting clinical governance and modernising NHS services.' However, the same document reports that 'one-third of NHS staff have not had development needs identified and that training needs across services are not systematically identified'.
Training needs analysis (TNA) is a formal term used to describe part of a training strategy where 'training or learning objectives are established, knowledge is mapped, gaps are identified and appropriate action is taken to meet needs' (Pedder, 1998). Assessing mental health training needs in the primary care nursing workforce is important for a number of reasons. TNA can:
- Identify the skills needed by the workforce to provide high-quality care and intervention;
- Inform education commissioners and providers of staff training needs;
- Identify skills deficits that may be a barrier to delivering standard two of the national service framework (NSF);
- Ensure that training is focused on areas that are of direct relevance to the health needs of the local population, for example the skills required to deliver health improvement programmes;
- Ensure that workforce development needs are in line with the delivery of government health policy, such as the delivery of NSFs;
- Provide guidance for community mental health nurses acting as link workers supporting primary care colleagues.
TNA, however, is not without its methodological or philosophical problems. For example, the self-perceived needs of practitioners may be incompatible with policy recommendations or organisational needs.
Furthermore, continuing professional development and lifelong learning are key principles of clinical governance that organisations should already be pursuing for their staff.
Strategic thought is needed on how these relate to such things as local health needs and health improvement programmes. Education providers must ensure they develop close links with local trusts so that TNA data can be used when contracting and commissioning training.
Determining mental health training needs
A TNA was conducted in March 2001 during training and information sessions attended by primary care nurses working in a London borough that has extremes of affluence and social deprivation. After each session participants were given a questionnaire to complete. The sample size was 90 and 69 were returned fully completed, a response rate of 77%. Incomplete responses were not included in the report.
The sample represented a cross-section of nursing disciplines in primary care, but was predominantly made up of health visitors (23) and practice nurses (26). It included one school nurse, one ethnic outreach nurse and four learning disability nurses.
Analysis of respondents' replies
The analysis found that 73% of the sample had no formal mental health care experience and 65% had no formal mental health care training, but respondents were eager to attend training. A majority (62%) had frequent contact with clients experiencing mental health problems of varying degrees.
The analysis also identified factors that deter staff from attending training. Getting enough time off work to attend training figured prominently, with 65% of respondents stating that this was a barrier. An equally large number, 62%, cited workload as a barrier, while 46% said location was an important factor that would influence their attendance. Most preferred practice-based training. Clinic times were identified as an obstacle by 26%.
These are important factors for specialist mental health services and education providers to remember, as primary care staff do not necessarily work a traditional nine-to-five day. Any training sessions would need to fit around this.
Weekday training was the most widely preferred time (17%), but respondents had no obvious preference for training in the morning or afternoon. The preferred modes of teaching were formal sessions (26%), face-to-face sessions in a clinic setting (22%) and group work (16%).
Individual preferences for training needs
The questionnaire also asked participants to select subject areas in which they would like training.
Not surprisingly, the categories nurses selected were influenced by the client groups that they were seeing. For example, requests for training about postnatal depression came mainly from health visitors, whereas requests for training in how to recognise and manage the side-effects of medication came mainly from practice nurses administering medication to clients. Adolescent mental health care was also cited, with specific emphasis on exam times when stress is a common factor.
It would be fair to say that some areas identified should be clearly delineated. For example, assessing suicide should, at best, only be done after rigorous training. Many mental health practitioners and educators would question whether or not non-specialist mental health practitioners should be carrying out this kind of assessment.
The study's limitations
The study's modest sample size makes it difficult to extrapolate the findings. Future studies must extend to the entire primary care workforce, including reception staff, allied health professionals and GPs. Nevertheless, the study gives strong indications of training needs relevant to mental health educators and practitioners working in similar areas.
Although the sample was small, it was encouraging to see that the training needs nurses identified closely mirrored areas set out in government policy.
This type of exercise may become more commonplace as service providers seek to ensure that staff have the skills needed to deliver the health care policy agenda.
This study highlights potential areas for concern regarding implementation of standard two of the NSF for mental health. More than half the sample had had no formal mental health care training or work experience, which is likely to impede the successful implementation of this particular standard.
The study also shows the need for a definition of the term 'common mental health problem', as what is understood by this differs between secondary and primary care. For example, schizophrenia is a common diagnosis in secondary mental health care and is a service priority; in primary care, mental health problems should have a different emphasis, targeting illnesses such as mild depression. However, in our sample, some practice nurses were giving depot injections to clients diagnosed with schizophrenia. These nurses, therefore, need to have some understanding of the illness and knowledge of possible complications arising from patients' treatment.
Nurses' need for training about major mental health issues was also evident, and careful consideration will have to be given to how these needs can be met.
Making a Difference (DoH, 1999) states: 'Nurses, midwives and health visitors must play a full part in developing and implementing national service frameworks and clinical governance with more nurse-led primary care services to improve accessibility and responsiveness.'
Extending nursing roles means that appropriate training needs will have to be identified to ensure delivery of high standards of care, especially in relation to mental health and primary care. If primary care services are to achieve standard two of the NSF for mental health, consideration must extend beyond financial resources to how well the workforce is developed and trained. Using a TNA to identify and map skills will help to marry policy to implementation.
Community mental health nurses who provide primary care liaison will need to be trained to give basic support, and advice or information on available services. They will also need to know how to run workshops on assessing and managing minor mental health problems.
Finally, involving service users and carers in training activities is an area that merits further exploration if local stakeholders' opinions are to be fully represented.