What do nurses in acute trusts need to provide mental health care?

A local survey of nurses in acute trusts showed the learning development needs and challenges around providing care to patients with mental health needs among general nurses. This article comes with a handout for a journal club discussion

Abstract

A survey of nurses working in seven acute trusts across Wessex was conducted to better understand the learning development needs and challenges around providing mental health care. The results led to a regional network being created to deliver improvements in the care of patients with mental health needs in the acute setting.

Citation: Herbert S, Hetherington T (2021) What do nurses in acute trusts need to provide mental health care? Nursing Times [online]; 117: 6, 44-46.

Authors: Sarah Herbert is divisional head of nursing, University Hospital Southampton NHS Foundation Trust; Tina Hetherington is deputy chief nurse, Portsmouth Hospitals University NHS Trust.

Mental illness is the fifth most common health disorder globally (Whiteford et al, 2013). There is evidence that patients with mental illness receiving care in hospitals experience disparities in care and inequities in treatment in healthcare systems (Druss et al, 2011). Physical conditions in people with mental illness are common; figures show they have higher rates of diabetes mellitus, cardiovascular disease, pulmonary disease, infectious disease and certain types of cancer than the general population (Hert et al, 2011).

In serious mental illness, such as schizophrenia, schizoaffective disorder and bipolar disorder, there is also a risk of non-psychiatric hospitalisation due to self-harm, self-neglect and/or reduced healthcare access and medically unexplained symptoms (Jayatilleke et al, 2018). Druss et al (2011) noted that people with mental illness die, on average, 8.2 years earlier than the rest of the population – typically from physical comorbidities. Concerns about the gap between mental and physical health care were also raised by the National Confidential Enquiry into Patient Outcome and Death’s (2017) report, Treat as One.

The NHS Long Term Plan (NHS England, 2019) identified the importance of assessment and support for mental health needs. It outlined NHS England’s commitment to putting mental health care on a level footing with physical health services. Specifically, The NHS Long Term Plan points out that patients with mental health concerns often present to acute trusts via an emergency pathway, due to the lack of ‘core 24’ (ie, available 24 hours a day, seven days a week) community crisis services. The overarching ambition is:

  • To ensure no acute hospital is without an all-age mental health liaison service in emergency departments and inpatient wards by 2020-21;
  • That at least 50% of these services should meet the core 24 service standard as a minimum.

There is evidence that nurses’ attitudes towards, and knowledge of, mental illness affects the care they deliver (de Jacq et al, 2016; Clarke et al, 2014). There is stigma and discrimination towards those experiencing mental illness, which is a barrier to care and recovery (Sartorius, 2007). The acute hospital setting may not be the most appropriate place for patients with mental health needs, as they are often in a vulnerable position, require compassionate care that provides a feeling of safety as well as upholding their human rights (Care Quality Commission, 2020). Patients with mental health conditions can be stigmatised in the acute care system due to a lack of understanding, knowledge and an associated burden of responsibility felt by clinical staff (Perry et al, 2020).

The CQC (2020) raised concerns that people with mental health needs do not always receive the right level of care. Furthermore, it identified a lack of joined-up working between acute and mental health services, leading to delays in assessment; this is compounded by a shortage of mental health beds, which results in longer stays in the acute setting.

Project background

As part of a Florence Nightingale Foundation Leadership Scholarship, two senior nurse leaders in neighbouring acute trusts independently recognised the growing challenges of mental health provision in their organisations. These concerns were compatible with those described by the CQC (2020), Kingston (2019), de Jacq et al (2016) and Clarke et al (2014). There were increasing numbers of clinical incidents relating to the care of mental health patients across both trusts that highlighted a deficit in the skills and confidence of the nursing workforce.

Staff reported feeling unsupported or unprepared to meet patients’ mental health needs. This resonated with the CQC’s (2020) findings that mental health training for staff across acute trusts was varied and focuses on legislation such as the Mental Capacity Act 2005, rather than the Mental Health Act 1983 or assessing and supporting people with mental health needs.

Changes to pre-registration nurse training, as outlined in the NMC’s (2018) Future Nurse proficiency standards, ensure all newly qualified nurses receive training in mental health care. However, this does not address the knowledge, learning and development needs in the existing registered workforce.

Project aims

Our aim was to:

  • Understand the learning development needs of our nursing workforce around mental health care;
  • Identify challenges across the system.

We found relevant reports that highlighted the barriers to caring for people with mental health problems in acute care settings – for example, Muir (2017) acknowledged a need for increased mental health training and education for general nurses  – yet we found a paucity of evidence that nurses working in acute settings had been specifically asked to highlight their concerns about caring for this patient group and how the concerns might be addressed.

Approach

To see if there was a region-wide appetite for this project, we reached out to fellow nurse leaders in seven acute trusts in Wessex. We asked whether our experience was mirrored in their organisations and, if so, they would be willing to work collaboratively to better understand the issues and make improvements in care provision.

We created an online survey to gather nurses’ views on the main challenges they faced in caring for patients with mental health needs. Before designing and sharing the survey, we sought input from clinicians working in mental health; this reassured us that the survey questions would provide useful information.

We asked three questions:

  • Question1: what are your biggest concerns in caring for people with mental health needs?
  • Question 2: what would help you improve your care to mental health patients?
  • Question 3: what difference would these improvements make to you and your patients?

Multiple-choice options were generated for questions 1 and 2 based on expert guidance, and there was a free-text option for question 3. The survey was anonymised but details of the trust and the banding of the respondent’s role were collected. 

Findings

The survey was sent to the heads of nursing of seven acute trusts in Wessex, who shared it with adult nursing staff. We received 412 responses from band 5 to band 7 nursing staff; 409 answered all three questions.

Planning for patient safety and knowledge of mental health sections were the two main areas of concern reported by nursing staff (Fig 1). Nurses said having access to mental health anticipatory care planning in the event of a crisis, as well as competence-based training would enable them to improve care (Fig 2).

What do nurses in acute trusts need to provide mental health care?

Although there were small differences across trusts, the answers staff gave on their main concerns were consistent, allowing us to identify key themes. Nurses of a higher band (band 7) reported the same concerns as those in junior bands (band 5 and 6), suggesting that acute nursing experience does not equate to increased competence in caring for patients with mental ill health.

There was a variety of responses about the difference proposed improvements would make. Responders felt any improvement identified would only result in positive outcomes for staff and better patient experience, such as:

  • Reduction in violence and aggression;
  • Increased patient safety;
  • Improved patient pathway efficiency;
  • Increased skills and confidence.

Discussion

Our survey reflects not only some of what has already been reported in the literature, but also individual nuances of our organisations. We noted that the desire for mental health education and competencies reported by staff resonates with Clarke et al’s (2014) observation that registered nurses can lack the necessary skills and knowledge to provide appropriate care to those with mental illness. This was shown by our respondents’ desire to know more detail about the Mental Health Act 1983 and sectioning.

It aligns with the argument that nurses in acute care settings feel ill-prepared to care for persons with both physical and mental illness (Hall et al, 2016). Kingston (2019) made a further relevant argument, which concerned the need for a better understanding of the relationship between training and education, and negative attitudes and bias among nurses.

Our findings also identified that although literature is available on mental health or general nurses’ attitudes and knowledge of mental health (Clarke et al, 2014; de Jacq et al, 2016; Kingston, 2019), less is known about the similarities and differences between levels of experience. Our survey found that, regardless of band, the challenges reported were the same.

Finally, our survey identified the need for greater use of anticipatory care plans to support nurses lacking knowledge in this area when caring for patients with mental health needs in acute settings. Anticipatory care plans (known as crisis plans in mental health) are commonly used in community settings but are often not shared with acute care settings; they give nurses the information required to support individualised approaches to patients in crisis.

Implications for practice and future plans

These survey results are a reminder of the inequities and disparity of care that people with mental illness may experience because of a lack of skills, knowledge or confidence in the assessment and support of their mental health needs, the requirements of the Mental Health Act, and beliefs and attitudes towards mental illness. We must be aware, in our daily practice, that care for a person with mental illness must combine assessment and management of physical and mental health needs; it is important to be aware of the parameters of our individual knowledge, as well as considering the stigma and discrimination a person may face.

The results were shared and discussed with participating trusts. A collaborative working network was agreed to develop a consistent regional approach to the assessment and care of mental health patients. The Wessex Regional Network Development Group was then established, and links formed with the patient experience teams of a mental health provider trust in our system. This is consistent with the principle of putting the patient experience at the centre of all improvement work. The aim of the network is to share best practice, knowledge and experience to enable nurses to deliver high-quality care to patients with mental health concerns.   

As a result of our survey  we identified gaps in the knowledge and skills of our nursing workforce. This challenged us to consider what good care means from our patients’ point of view, and how to include the lived experience of patients in our nursing education curriculum for mental health. We are planning to develop principles of care, coproduced with patients, that outline what care those with mental health needs should expect to receive in the acute setting. We also plan to develop a self-assessment tool for acute trusts to enable them to identify, at a local level, the opportunities to support their staff to consistently deliver these principles of care.

Key points

  • Nurses recognise they may lack skills and knowledge in looking after patients with mental health needs
  • Level of experience in acute nursing does not equate to better knowledge or competence in mental health care
  • Nurses can identify what would improve the care they deliver to patients with mental health needs Improvements would benefit both patients and staff
  • Collaborative working across a wider regional system gives greater understanding of a problem and creates a more compelling case for change

References

Care Quality Commission (2020) How are People’s Mental Health Needs Met in Acute Hospitals, and How Can This be Improved? CQC.

Clarke D et al (2014) Emergency department staff attitudes towards mental health consumers: a literature review and thematic content analysis. International Journal of Mental Health Nursing; 23: 3, 273-284.

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Druss BG et al (2011) Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Medical Care; 49: 6, 599-604.

Hall A et al (2016) Educating emergency department nurses about trauma informed care for people presenting with mental health crisis: a pilot study. BMC Nursing; 15: 21.

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Muir D (2017) Neglect of the mental health problems in acute general hospital inpatients. Nursing Times [online]; 113: 6, 48-49.

National Confidential Enquiry into Patient Outcome and Death (2017) Treat as One: Bridging the Gap Between Mental and Physical Healthcare in General Hospitals. NCEPOD.

NHS England (2019) The NHS Long Term Plan. NHS England.

Nursing and Midwifery Council (2018) Future Nurse: Standards of Proficiency for Registered Nurses. NMC.

Perry A et al (2020) Stigmatisation of those with mental health conditions in the acute general hospital setting: a qualitative framework synthesis. Social Science and Medicine; 255: 1112974.

Sartorius N (2007) Physical illness in people with mental disorders. World Psychiatry; 6: 1, 3-4.

Whiteford HA et al (2013) Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet; 382: 9904, 1575-1586.