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A National Survey of Practice Nurse Involvement in Mental Health Interventions

A National Survey of Practice Nurse Involvement in Mental Health Interventions
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  A national survey of practice nurseinvolvement in mental health interventions Richard Gray RN BSc(Hons) Tutor, Section of Psychiatric Nursing, Institute of Psychiatry  Ann-Marie Parr Research Worker, Section of Psychiatric Nursing, Institute of Psychiatry  Susan Plummer BA MSc RN RNT Research Worker, Section of Psychiatric Nursing, Institute of Psychiatry  Tom Sandford BSc(Hons) RMN Mental Health Advisor, Royal College of Nursing, London Susan Ritter MA RGN RMN Lecturer, Section of Psychiatric Nursing, Institute of Psychiatry  Rosie Mundt-Leach BSc(Hons) RN MSc Research Worker, Section of Psychiatric Nursing,Institute of Psychiatry  David Goldberg KB MA BM BCh DM MSc FRCP FRCPsych Professor of Psychiatry, Department of Psychiatry, Institute of Psychiatry  and Kevin Gournay CBE MPhil PhD CPsychol AFBPsS RN FRCN Professor of Psychiatric Nursing, Section of Psychiatric Nursing,Institute of Psychiatry, London, England  Accepted for publication 10 February 1999 GRAY R.,GRAY R., PARRPARR A.-M.,A.-M., PLUMMERPLUMMER S.,S., SANDFORDSANDFORD T., RITTER S.,T., RITTER S., MUNDTMUNDT-LEACH R.,-LEACH R., GOLDBERG D.GOLDBERG D. && GOURNAYGOURNAY K. (1999)K. (1999) Journal of Advanced Nursing  30 (4), 901±906 A national survey of practice nurse involvement in mental health interventions Background: The move in the United Kingdom (UK) from institutional tocommunity care has led to an inevitable increase in the involvement of practicenurses (PNs) in mental health care. Around 20 000 PNs are currently workingin the United Kingdom (UK). However, the extent and nature of PN involvementin delivering mental health interventions has not been adequately explored. Aim: This study aimed to quantify practice nurses' involvement in deliveringmental health interventions in primary care settings. Method: A questionnairewas sent to a random sample of 1500 practice nurses registered with the PracticeNurse Forum at the Royal College of Nursing. Sixty per cent of questionnaireswere returned; however, once non-eligible respondents were removed anadjusted response rate of 54% was achieved. Results: Practice nurses play a Correspondence: Richard Gray, Section of Psychiatric Nursing,Institute of Psychiatry, De Crespigny Park, London SE5 8AF, England.E-mail:  Ó 1999 Blackwell Science Ltd 901  Journal of Advanced Nursing  , 1999, 30 (4), 901±906 Issues and innovations in nursing practice  signi®cant role in the assessment and treatment of mental health problems, mostfrequently via the administration of depot antipsychotics and the screening fordepression. However, antipsychotic side-effects were infrequently monitoredand PNs' understanding of treatment issues in depression is poor. These®ndings may be associated with the reported lack of mental health training thatPNs have received. Conclusions: The ®ndings of this study have importantimplications for the training of practice nurses in mental health, speci®cally inthe areas of medication management and the detection of mental disorders. Keywords: depression, education, mental health, practice nurses, psychosis INTRODUCTION Recent estimates suggest that 20% of primary care atten-dees suffer from well-de®ned mental disorders, and thatthis increases to approximately 40% if minor disorders areincluded (Goldberg 1995). Although the Department of Health (England) has recognized that nurses employed ingeneral practice (PNs) are spending a signi®cant amount of time working with people with mental health problems(DepartmentofHealth/RoyalCollegeofNursing,DoH/RCN1996) the examination of the exact role of the PN has beenlargely ignored in recent large scale surveys (Atkin et al. 1993, Paxton et al. 1996). Few studies have speci®callyexamined PN involvement in mental health interventions(Thomas & Corney 1993, Armstrong 1997).Thomas & Corney (1993) surveyed 98 PNs working insouth-east England, achieving a response rate of 72%.Results demonstrated that 89% of PNs regularly seepatients with mental health problems, 87% reported thatthey felt inadequately trained and 91% wanted moretraining in this ®eld. However, the type of mental healthinterventions PNs were involved in delivering was notexamined.Sutherby et al. (1992) in a survey of 101 primary carenurses reported that they had frequent contact withpatients with mental health problems. Nearly half (44%)of respondents indicated that a third or more of theirpatients had mental illnesses, with PNs stating thatthey were frequently expected to administer depotantipsychotics despite feeling inadequately trained andsupervized in the task. In a census of 12 589 PNs by Atkin et al. (1993) 43 á 4% reported that identifying the earlysigns of anxiety and depression was part of their role.A survey conducted by Armstrong (1997) focusedspeci®cally on PNs involvement in the assessment andtreatment of depression. Of the 3000 PNs sampled fromthe National Asthma Training Centre database, the major-ity of the 1006 respondents felt that they did not haveenough knowledge about the diagnosis and treatment of depression and did not feel con®dent working with thesepatients. However, the low response rate (30%), poorsampling techniques and speci®c focus on depression,necessitates a large scale, representative study examiningPNs' involvement in a range of mental disorders.Recent studies have demonstrated that PNs detect only23% of cases of depression (Plummer et al. 1997). Thetraining of PNs in the detection and management of depression is currently being evaluated in a large-scalerandomized controlled trial (Plummer et al. 1997). Pilotdata have indicated that with adequate training it may bepossible to improve PNs' ability to detect and treatdepressed patients (Mann et al. 1998).Whilst there is clear evidence that PNs are involved indelivering mental health interventions, the nature andextent of their involvement is unclear. This study aimed to bridge this gap by undertaking a national survey of PNs'involvement in delivering mental health interventions. THE STUDYMethod Because no national database or register of PNs exists, thesample for this survey was drawn from a membershipdatabase of the Practice Nurse Forum at The Royal Collegeof Nursing (RCN). The Forum has approximately 15 000members from across the United Kingdom (UK). Althoughmembers of the Forum do not have to be PNs the vastmajority has, at some point, worked in that capacity. Justi®cation for the use of this database was reported byAtkin et al. (1993) in their census of PNs. They observedthat most PNs (no ®gure reported) were members of theRCN. This suggests that the RCN database will provide arepresentative sample that can be con®dently generalized.Toestimatetherequiredsamplesizeapowercalculationwas performed using ARCUS. This programme has beendeveloped speci®cally to estimate sample sizes forsurveys. With a margin for error of 5% and a 95%con®dence interval, basedonthe assumptionthat thereare20 000 PNs working in the UK and 5% administer depotantipsychotics several times a week, a sample of 784 wasrequired for this study. To meet these power requirements,andassumingaresponserateof60%,asampleof1500PNswas randomly selected from the RCN database. R. Gray  et al. 902 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing  , 30 (4), 901±906  Questionnaire A 42-item questionnaire was developed based on previousresearch (Atkin et al. 1993, Thomas & Corney 199311,Armstrong 1997) and consultation with a group of clinicaland academic experts (a practice nurse advisor, professorsof nursing and psychiatry, a consultant psychiatrist and ageneral practitioner). Advice was also sought from theDepartment of Health and the Royal College of Nursing.The questionnaire was designed to be brief and easy tocomplete. A covering letter explained the nature andpurpose of the study and two consent forms were sentwith the questionnaire. The questionnaire was dividedinto ®ve areas: demographic information, PNs' caseload,involvement with depressed patients, involvement withpsychotic patients, and current and future trainingrequirements.Information about the composition of caseloads wasobtained by asking PNs to estimate the proportion of patients seen in the last 4 weeks who were suffering fromeither serious and enduring mental disorders, such asschizophrenia or manic depression, or other mental healthproblems, such as mild depression, anxiety or a phobia.Statements about the treatment of depression were ratedon a ®ve-point scale ranging from agree to disagree. Theresearch group paid considerable attention to ensuringthat questions were neutral and not leading (a copy of thequestionnaire is available on request from the authors).Questionnaires were sent on 1 September 1997. Follow-up questionnaires and a reminder letter were sent 8 weekslater if nurses had not responded. Respondents wereasked to sign and return a completed consent form withthe questionnaire. If written consent was not obtainedPNs' questionnaires were not included in the study. Results Response rates and non-response bias Of the 1500 questionnaires sent out 903 (60%) werereturned. Of these 175 were invalid Ð 159 becauserespondents had either never or were not currentlyworkingaspracticenursesand16werereturnedunopenedpackages Ð an overall response rate of 54%. Sixty-eightPNs responded to the questionnaire but refused to partic-ipate, leaving 640 valid questionnaires.The 46% of PNs who did not respond may represent asigni®cant non-response bias. However, given that 195respondents were not currently, or had never worked as, apractice nurse it is likely that these reasons apply to aproportion of the non-responders which may reduce thenon-response bias. Demographics Of PNs who responded, 638 (99 á 7%) were female and two(0 á 3%) were male. The majority of PNs classi®ed them-selves as white ( n  622; 97%) with 18 (3%) respondentsfrom other ethnic groups. The mean age of PNs was43 years ( SSDD 8 á 16; range 26±64).All PNs held a professional quali®cation as either a stateregistered nurse (SRN; n  398; 62%) or a registeredgeneral nurse (RGN; n  242; 38%). Respondents heldjoint registration in the following specialist areas: regis-tered midwives ( n  166; 26%), registered sick children'snurses ( n  22; 3 á 5%) and registered mental nurses( n  18; 3%). One hundred and seventy-®ve respondents(27%) had been educated to diploma level or higher. The practice setting  Fifty-one per-cent of respondents worked for afund-holding general practitioner (GP), and 43% for anon-fund-holding GP. Six per cent of practice nursesworked in other settings including Ministry of Defenceand NHS/Community Trusts. PNs worked on average24 á 5 hours per week and had worked within the practicefor a mean of seven years. Practices had a median numberof 7400 registered patients ( SSDD 4386, range 45±32 000).Sixty-four per cent of practices had attached CPNs, 56%had attached counsellors, 18% attached clinicalpsychologists and 4% had other attached mental healthprofessionals (alcohol/addictions, relate, family therapy). Case-loads The estimated mean number of patients seen in the last 4weeks by respondents was 309. Ten per cent of PNs'caseloads were reported as having psychological or mentalhealth problems. Serious and enduring disorders such asschizophrenia made up 1 á 5% of PNs' caseloads and anestimated 2% of patients seen by PNs were takingantipsychotic medication. Practice nurses and depression Approximately half of respondents reported thatdepressedpatientsaskforinformationaboutthesymptomsof depression (48%) and about antidepressant medication(51%). It was also indicated that 44% of PNs gave infor-mation and advice to patients and their families regardingthe nature of depression, 44% about the use of antidepres-sant medication and 56% about counselling in depression.Seventy-®ve per cent of respondents saw counselling asthe best treatment approach for mildly depressed patients.Thirty-three percent agreed with the statement that cogni-tive behaviour therapy is bene®cial in the treatment of depression. Forty-two per cent of PNs did not agree withthe statement that antidepressant medication was the bestmethod of treating severely depressed patients. Fifty-twoper cent of respondents stated that antidepressants were not  drugs of addiction. The administration of antipsychotic medication On average 39% ( n  250) of PNs never administereddepot antipsychotics. However, the majority (61%, Issues and innovations in nursing practice Practice nurse survey  Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing  , 30 (4), 901±906 903  n  390) reported administering depots at least once amonth. Of these, 216 (55%) reported monitoring patientsfor side-effects. The side-effects most frequently moni-tored by PNs giving depots were weight gain ( n  231,59%), hypotension ( n  180, 46%) and abnormal invol-untary movements ( n  178, 45%). The side-effects thatwere most infrequently monitored were sexual dysfunc-tion ( n  101, 26%), urinary problems ( n  123, 31%) and blurred vision ( n  126, 32%). Involvement in mental health interventions The mental health interventions that PNs weremost frequently involved in were administering depotantipsychotics ( n  392, 61%), ensuring compliance withantipsychotic medication ( n  212, 33%) and monitoringthe side-effects of medication ( n  189, 30%). Contact with mental health professionals Respondents reported that the mental health professionalswith whom they have most contact were CPNs (30% somecontact, 7% frequent contact) and counsellors (29% somecontact, 8% frequent contact). PNs reported that they hadvery little contact with psychiatrists (96% no contact),social workers (87% no contact) or psychologists (93% nocontact). Forty per cent of PNs reported having no contactwith mental health professionals.PNs' involvement in the arrangements made under theCare Programme Approach (CPA) was also explored. Lessthan 1% of respondents reported that they were alwaysinvolved in arrangements made under the CPA. Nine percent reported that they were sometimes involved and 90%stated that they were never involved in arrangementsmade under the CPA. Mental health training  It was found that 451 practice nurses (70%) had receivedno mental health training in the last 5 years. Of the 30%who had attended at least one course relating to mentalhealth, depression study days, counselling skills training,and stress and anxiety management, were the mostcommon.Respondents ranked 10 key areas for mental healthtraining (1  most important, 10  least important). Theseresults are reported in Table 1. DISCUSSION The demographic pro®le of the population (age, gender,ethnicity) for this study is comparable to the nationalcensus of 16 488 PNs (Atkin et al. 1993). These twostudies are also comparable in terms of number of hoursworked each week by PNs, length of time working in thepractice, and settings where respondents work. Althoughthe response rate for this study was lower than thatreported by Thomas & Corney (1993), the sample wasclose to that estimated by the power calculation,suggesting that the results can be generalized.Despite the ®ndings of Goldberg (1995) who reportedthat up to 40% of primary care attendees might besuffering mental health problems, respondents in thepresent study reported that they saw relatively fewmentally ill patients. This result may support the ®ndingsof Plummer et al. (1997) that mental health problems tendto go unrecognized by PNs. Alternatively, this result may be due to the fact that people with mental health problemsare not seen by PNs but are treated by other members of the primary health care team, such as CPNs and counsel-lors. However, the effect of having a counsellor attached tothe practice was to increase signi®cantly the number of patients with mental health problems seen by PNs( t  (584)  A 3 á 09, P   0 á 002). Attached CPNs had no signi-®cant effect on the number of patients with mental healthproblems seen by PNs. Therefore, it can be concluded thatif either counsellors or CPNs are attached to a practice thenumber of mentally ill patients seen by PNs will not bereduced. InterventionMean rank (1 most important,10 least important)95% con®denceintervalsSigns and symptoms of mental disorder 2 á 32 2 á 2±2 á 5Anxiety management 2 á 97 2 á 7±3 á 1Supportive psychotherapy/counselling 4 á 01 3 á 8±4 á 2Pharmacology 4 á 55 4 á 3±4 á 8Suicide prevention and self-harm 4 á 66 4 á 3±4 á 8Relaxation therapy 4 á 71 4 á 5±4 á 9Administering depot antipsychotics 4 á 74 4 á 6±5 á 2Interventions to enhance compliance 4 á 83 4 á 5±4 á 9Crisis intervention skills 4 á 86 4 á 6±5 á 1Behaviour modi®cation and therapy 5 á 55 5 á 4±5 á 8 Table 1 Respondent rankingof most important areas fortraining in relation to mentalhealth R. Gray  et al. 904 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing  , 30 (4), 901±906  The results of this study suggest that PNs arefrequently asked, and give advice, about the treatmentof depression. However, a poor understanding of treat-ment issues in depression was observed. A similar®nding was reported by Armstrong (1997) who demon-strated low levels of understanding about the diagnosis,management and treatment of depression among PNs.These ®ndings are predictable given that less than a thirdof PNs have attended a mental health course in the last5 years. However, given the high incidence of depressionin primary care settings, this study highlights an urgentneed for training in detection and management of depression.It was found that 61% of PNs administered depotantipsychotics at least once a month. This con®rms andquanti®es the ®ndings of Sutherby et al. (1992) thatpractice nurses are frequently expected to give depots.However, the present study also revealed that only 55% of PNs who gave depots monitored patients for adverseeffects of antipsychotics.Respondents ranked training in the signs and symptomsof mental disorder as the priority for training in relation tomental health. Given the likely under-recognition of mental health problems among the patients seen by PNs,training in the detection of mental disorders shouldfacilitate early intervention and treatment.The mental health interventions that PNs are mostfrequently involved in delivering are the administration of depot antipsychotics, ensuring compliance and moni-toring the side-effects of medication, even though PNsreport that generally, they have received little speci®ctraining in these interventions. However, respondentsdid not indicate that training in administering depotantipsychotics or in the use of interventions to enhancecompliance was a priority. This may suggest that PNs donot believe that helping patients to manage theirmedication is part of their role.Given the prevalence of mental health problems inprimary care it seems logical that PNs should be targetedstrategically for training for formal mental health roles.Such training would be in accord with the strategyproposed by Goldberg & Gournay (1997) which seeks toimprove mental health care delivery by strengtheningthe role of the primary care team. This is of course not anew idea; Shepherd et al. (1966) recognized this32 years ago.It is interesting to contrast PNs' reported priorities fortraining with those identi®ed by GPs. In a study byKerwick et al. (1998) both groups reported that training insupportive psychotherapy/counselling was a high prioritywhilst assessing suicidal risk was a low priority. Bothgroups stated that training in the prescribing and admin-istration of psychotropic medication was a low priority.However, there was disagreement on the need for crisisintervention skills, with PNs giving it a low and GPs ahigh priority. CONCLUSION This survey constitutes a comprehensive investigationinto the extent of PN involvement in mental health care. Itwas found that practice nurses are frequently involved indelivering mental health interventions such as the admin-istration of depot antipsychotics and the detection andmanagement of depression. However, there is evidencethat many instances of mental disorder go unrecognized by practice nurses. These ®ndings are not surprising giventhat the majority of PNs have received little mental healthtraining. Providing PNs with the necessary supervisionand training in mental health presents a signi®cantchallenge. CPNs, who are the psychiatric professionalsthat PNs have most contact with, could provide somesupervision. However, speci®c training initiatives willstill be necessary to equip PNs with the mental healthskills they need. Given the large number of PNs whorequire training the delivery of this training will need to beinnovative, potential methods may include distancelearning, the use of multimedia technology, or a nationalprogramme of skills workshops. However the training isprovided, what is clear from this study is that PNs areinvolved in working with people with mental healthproblems and need to learn more skills to treat thoseindividuals effectively. Acknowledgements This study was supported by a grant from Lilly Psychiatry. References Armstrong L. (1997) Do PNs want to learn about depression? Practice Nursing  8 , 21±26.Atkin K., Lunt N., Parker G. & Hirst M. (1993) Nurses Count: ANational Census of Practice Nurses. Social Policy ResearchUnit, University of York, York.Department of Health/Royal College of Nursing (1996) Guidelines for Practice Nurse Administration of Depot Medication. HMSO,London.Goldberg D. (1995) Epidemiology of mental disorder in primarycare settings. Epidemiologic Review  17 , 182±190.Goldberg D. & Gournay K. (1997) Maudsley Discussion Paper No.1. The General Practitioner, the Psychiatrist, and the Burden of Mental Health Care . Institute of Psychiatry, London.Kerwick S., Jones R., Mann A. & Goldberg D. (1998) Mental healthcare training priorities in general practice. British Journal of General Practice 47 , 225±227.Mann A.H., Blizard R., Murray J. et al. (1998) An evaluation of practice nurses working with general practitioners to treat Issues and innovations in nursing practice Practice nurse survey  Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing  , 30 (4), 901±906 905
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