‘‘Educate to care’: A training Educate to care’: A training needs analysis of Irish needs analysis of Irish

registered mental health registered mental health nurses in physical health and nurses in physical health and

physical health skills.physical health skills.

Brendan Power (RGN,RPN) Brendan Power (RGN,RPN) HSE – Dublin West/South West HSE – Dublin West/South West

Mental Health ServiceMental Health Service

MSc (Nurse/Midwifery Education)MSc (Nurse/Midwifery Education)

Dublin West/South West Region Dublin West/South West Region Dublin West/South West RegionDublin West/South West Region Population = 276,334 peoplePopulation = 276,334 people

Service predominantly community based in line with ‘Vision for Service predominantly community based in line with ‘Vision for Change’ (2006)Change’ (2006)

4 sector community mental health teams4 sector community mental health teams A service wide A service wide Psychiatry of Later Life ServicePsychiatry of Later Life Service A Service wide A Service wide Rehabilitation ServiceRehabilitation Service

Inpatient unit (Approved Centre) based in Tallaght HospitalInpatient unit (Approved Centre) based in Tallaght Hospital 52 acute beds = 23 male, 23 female, 6 bedded high observation 52 acute beds = 23 male, 23 female, 6 bedded high observation

unit. unit.

Lets begin…Lets begin…

Mental health nurses perform a broad Mental health nurses perform a broad range of tasks in a variety of differing range of tasks in a variety of differing settingssettings

HoweverHowever often the physical health often the physical health needs of consumers can often be needs of consumers can often be overlooked…overlooked… (Happell et al, 2012)(Happell et al, 2012)

Lets go back in time….Lets go back in time….

In the UK, the unmet physical health needs In the UK, the unmet physical health needs of mental health service users has been an of mental health service users has been an area of topic for over seventy years. area of topic for over seventy years.

(Phillips, 1934)(Phillips, 1934)

For over a century there has been a strong For over a century there has been a strong association between diabetes and association between diabetes and schizophrenia, even though the underlying schizophrenia, even though the underlying associations are unclear. associations are unclear. (Holt et al, 2005)(Holt et al, 2005)

Background to the Problem: Background to the Problem:

Individuals with a serious mental illness Individuals with a serious mental illness (SMI) have significant higher mortality rates, (SMI) have significant higher mortality rates, in comparison to the wider population, due in comparison to the wider population, due to untreated or under recognised physical to untreated or under recognised physical health conditions. health conditions.

(Harris et al, 1998; Ronis, 2008; Gray et al, 2009).(Harris et al, 1998; Ronis, 2008; Gray et al, 2009).

Many factors inhibit individuals with SMI Many factors inhibit individuals with SMI from receiving adequate physical from receiving adequate physical healthcare. healthcare.

(Phelan et al, 2001; De Hert, 2010; Hardy et al, 2010) (Phelan et al, 2001; De Hert, 2010; Hardy et al, 2010)

Nash (2010) defined three main Nash (2010) defined three main determinants influencing the physical determinants influencing the physical health of clients: health of clients:

1.1. Lifestyle factorsLifestyle factors

2.2. Social factors Social factors

3.3. Adverse drug reactionsAdverse drug reactions

Knowledge & PsychiatryKnowledge & Psychiatry The knowledge of health nursing has been immature The knowledge of health nursing has been immature

and in psychiatry compelled forward with the and in psychiatry compelled forward with the development of medical expansionism. development of medical expansionism. (Barker et al, (Barker et al, 1989 ;Meadows, 2003)1989 ;Meadows, 2003)

As medical knowledge and science advanced nurses As medical knowledge and science advanced nurses needed to know about the causes and treatments of needed to know about the causes and treatments of physical conditions.physical conditions.

(Sheridan, 2008)(Sheridan, 2008)

The adoption of a recovery approach has often The adoption of a recovery approach has often argued the need for mental health nursing to move argued the need for mental health nursing to move away from the medicalized psychiatric paradigm.away from the medicalized psychiatric paradigm.

(Barker et al, 2011)(Barker et al, 2011)

Physical Health & Mental health Physical Health & Mental health NursingNursing

Mental health nurses undertake routine Mental health nurses undertake routine risk assessments and often worry about risk assessments and often worry about the occurrence of death by suicide of the occurrence of death by suicide of service-users service-users (Gray et al, 2009)(Gray et al, 2009)

HoweverHowever, a large proportion of mortality in , a large proportion of mortality in people with SMI is due to physical people with SMI is due to physical diseasesdiseases (Leucht et al, 2007)(Leucht et al, 2007)

Physical Health & Mental health Physical Health & Mental health NursingNursing

Mental health nurse training should educate nurses to be fit for Mental health nurse training should educate nurses to be fit for practice and have adequate knowledge in the causes of ill health. practice and have adequate knowledge in the causes of ill health.

(Anderson et al, 2011)(Anderson et al, 2011)

Irish mental health service users should have their physical health Irish mental health service users should have their physical health needs met and nursing has a responsibility to undertake this as needs met and nursing has a responsibility to undertake this as being the largest professional group employed in worldwide mental being the largest professional group employed in worldwide mental health services. health services. (Udo et al, 2011; WHO, 2011)(Udo et al, 2011; WHO, 2011)

The knowledge deficits of mental health nurses in physical health The knowledge deficits of mental health nurses in physical health care have been widely published (Jones, 2003; Nash, 2005; 2009; care have been widely published (Jones, 2003; Nash, 2005; 2009; 2010) but no studies have been undertaken in the Republic of 2010) but no studies have been undertaken in the Republic of Ireland specifically to mental health nursing. Ireland specifically to mental health nursing.

Ireland is one of the only countries in the Ireland is one of the only countries in the world to have separate and core world to have separate and core undergraduate nurse training pathways undergraduate nurse training pathways

(Robinson et al, 2007)(Robinson et al, 2007)

Study Aims/Objectives Study Aims/Objectives

Utilizing a survey questionnaire design (Nash, 2005) the aim Utilizing a survey questionnaire design (Nash, 2005) the aim of this study was to:of this study was to:

To determine how many mental health nurses had previous To determine how many mental health nurses had previous training in physical healthcare.training in physical healthcare.

To explore do mental health nurses provide physical To explore do mental health nurses provide physical healthcare to individuals with in their care and what physical healthcare to individuals with in their care and what physical health conditions do they encompass in practicehealth conditions do they encompass in practice

To ascertain if mental health nurses would like further training To ascertain if mental health nurses would like further training in physical/general healthcare and what specific areas would in physical/general healthcare and what specific areas would they prefer to gain new knowledge in.they prefer to gain new knowledge in.

To identify the preferred methods of learning and associated To identify the preferred methods of learning and associated barriers that would inhibit the process.barriers that would inhibit the process.

To examine and estimate the frequency of physical health To examine and estimate the frequency of physical health conditions and associated exposure on weekly work routines.conditions and associated exposure on weekly work routines.

Study Design & SampleStudy Design & Sample

A quantitative non-experimental descriptive A quantitative non-experimental descriptive survey desurvey design sign

18 question self-report survey questionnaire 18 question self-report survey questionnaire (Nash, 2005) utilised. (Nash, 2005) utilised.

A purposeful sample of 153 (n =153) registered A purposeful sample of 153 (n =153) registered mental health nurses working within hospital and mental health nurses working within hospital and community areas in a mental health service in community areas in a mental health service in the Dublin West/South West regionthe Dublin West/South West region..

Ethics & Analysis Ethics & Analysis

Full ethics granted from the St James Full ethics granted from the St James /Tallaght hospital Ethics Committee/Tallaght hospital Ethics Committee

Access granted to utilize staff in hospital & Access granted to utilize staff in hospital & community areas by gate-keeper. community areas by gate-keeper.

Analysis undertaken with SPSS Version Analysis undertaken with SPSS Version 18.18.

Study Participants – Hospital (Approved Centre)Study Participants – Hospital (Approved Centre)

Mean years qualified Mean years qualified

= 11.24 (range 2 to 33 years; Standard = 11.24 (range 2 to 33 years; Standard Deviation 9.782)Deviation 9.782)

The mean length of a nurse in their current The mean length of a nurse in their current working role =6.617 years (range 0.5 to working role =6.617 years (range 0.5 to 20; SD 6.9170).20; SD 6.9170).

Study Participants – Community AreasStudy Participants – Community Areas

Mean years qualified Mean years qualified

= 15(range 2 to 42 years; Standard = 15(range 2 to 42 years; Standard Deviation 11.3849)Deviation 11.3849)

The mean length of a nurse in their current The mean length of a nurse in their current working role =3.98 years (range 0.5 to 17; working role =3.98 years (range 0.5 to 17; SD 4.4166).SD 4.4166).

Findings – Previous Findings – Previous Experiences Experiences

Nurses in the approved centre had Nurses in the approved centre had higher levels of experience (73.7%) higher levels of experience (73.7%) and training (42.1%) in physical and training (42.1%) in physical healthcare when compared to the healthcare when compared to the community where there was a higher community where there was a higher incidence of mental health nurses with incidence of mental health nurses with a general nursing qualification (33% a general nursing qualification (33% CA, 21.1% AC).CA, 21.1% AC).

Most experience of training in physical Most experience of training in physical healthcare was reported occurring healthcare was reported occurring during training (undergraduate and during training (undergraduate and general), in previous employment and general), in previous employment and through daily work exposure.through daily work exposure.

Do You hold a General Nursing Qualification?

0

10

20

30

40

50

60

70

80

90

Yes No

%Approved Centre

Community Areas

Findings – Providing physical Findings – Providing physical healthcarehealthcare

Nurses in both areas Nurses in both areas provide physical provide physical healthcare to service healthcare to service usersusers

Approved Centre – Yes Approved Centre – Yes (84.2%)(84.2%)

Community Area – Yes Community Area – Yes (59.3%) (59.3%)

Do you currently provide physical healthcare to your clients?

0102030405060708090

Yes No missing

%Approved Centre

Community Areas

Findings – Care Provision Findings – Care Provision (Approved Centre) (Approved Centre)

The highest areas (≥ 50%) for nurses providing The highest areas (≥ 50%) for nurses providing care in the approved centres was in the areas of: care in the approved centres was in the areas of:

Pain relief (84.2%) Pain relief (84.2%) Skin conditions (78.9%)Skin conditions (78.9%) Diabetes (73.7%)Diabetes (73.7%) Tissue viability (63.2%)Tissue viability (63.2%) Cardiovascular conditions (68.4%)Cardiovascular conditions (68.4%) Respiratory conditions (57.9%)Respiratory conditions (57.9%) Substance Detoxification (57.9%)Substance Detoxification (57.9%)

Findings – Care Provision Findings – Care Provision (Community Areas) (Community Areas)

The highest areas (≤50%) for nurses providing The highest areas (≤50%) for nurses providing care in the community areas was in the areas care in the community areas was in the areas of: of:

Diabetes (44.4%)Diabetes (44.4%) Cardiovascular conditions (29.6%)Cardiovascular conditions (29.6%) Respiratory conditions (11.1%) Respiratory conditions (11.1%) Skin conditions (18.5%)Skin conditions (18.5%) Pain relief (33.1%) Pain relief (33.1%) Substance detoxification (25.9%).Substance detoxification (25.9%).

Findings – Care Provision Findings – Care Provision

Other areas reported by nurses in both areas provide Other areas reported by nurses in both areas provide included: included:

Epilepsy Epilepsy Health promotion Health promotion Medication education Medication education Metabolic screening Metabolic screening Palliative carePalliative care Weight management Weight management Infection control Infection control Continence careContinence care

The highest areas where staff in the The highest areas where staff in the Approved Centre identified for further Approved Centre identified for further knowledge development were in the areas knowledge development were in the areas of: of:

Diabetes (68.4%)Diabetes (68.4%)Health education and promotion (52.6%)Health education and promotion (52.6%)Managing minor illness (52.6%) Managing minor illness (52.6%) Coronary artery disease (52.6%)Coronary artery disease (52.6%)

Findings – Developing Findings – Developing KnowledgeKnowledge

Findings – Developing Findings – Developing KnowledgeKnowledge

The highest areas where staff in the The highest areas where staff in the community areas identified for further community areas identified for further knowledge development were in the areas knowledge development were in the areas of: of:

Assessment skills for physical health Assessment skills for physical health (70.4%); (70.4%);

Diabetes management (59.3%)Diabetes management (59.3%)Obesity management (51.9%)Obesity management (51.9%)

Findings – Developing Findings – Developing KnowledgeKnowledge

Both areas reported low findings in Both areas reported low findings in acquiring new knowledge into smoking acquiring new knowledge into smoking cessation cessation

Approved Centre – Yes (15.9%)Approved Centre – Yes (15.9%)

Community Area – Yes (14.8%)Community Area – Yes (14.8%)

Findings – Programme Findings – Programme participationparticipation

Approved Centre: Would you be willing to attend training in physical /general health issues in Mental

Health Care?

89.50%

5.30%

Yes

No

89% of nurses both in in the 89% of nurses both in in the Approved Centre and Approved Centre and community areas reported community areas reported they would like to participate they would like to participate in physical health/general in physical health/general health traininghealth training

Community Areas: Would you be willing to attend training in physical/general health issues in Mental

Health Care?

88.90%

3.70%

Yes

No

Findings – Barriers to Programme Findings – Barriers to Programme participationparticipation

Nurses subjectively reported such barriers Nurses subjectively reported such barriers that would inhibit training would include: that would inhibit training would include:

FundingFundingCurrent staff shortagesCurrent staff shortagesLocal service oppositionLocal service oppositionPerceptions of general nursesPerceptions of general nursesPoor course structure and the Poor course structure and the Lack of qualification after completionLack of qualification after completion

Findings – Preferred Teaching Findings – Preferred Teaching MethodsMethods

The preferred method of learning new The preferred method of learning new knowledge in physical health skills was knowledge in physical health skills was through formal teaching methods through formal teaching methods

Approved Centre - 68.4%Approved Centre - 68.4%Community Area - 71%Community Area - 71%

Findings – Least Preferred Findings – Least Preferred Teaching MethodsTeaching Methods

The least preferred method of learning new The least preferred method of learning new knowledge in physical health skills was knowledge in physical health skills was through the use of audio methods (tapes, through the use of audio methods (tapes, pod-casts) pod-casts)

Approved Centre – 89.5%Approved Centre – 89.5%Community Area - 92.6%Community Area - 92.6%

Findings – Estimated weekly Findings – Estimated weekly exposureexposure

What is the level of impact of physical/general health care problems on your practice?

01020304050607080

Approved Centre

Community Areas

Findings – Estimated weekly Findings – Estimated weekly exposureexposure

The current impact of physical health on The current impact of physical health on current practice had the highest current practice had the highest incidences in the approved centre incidences in the approved centre occurring daily (68.4%) in comparison to occurring daily (68.4%) in comparison to community areas. community areas.

Community areas reported the impact of Community areas reported the impact of physical health on practice occurring on a physical health on practice occurring on a weekly basis (48.1%).weekly basis (48.1%).

Limitations: Limitations:

Low response rateLow response rate

Limitations of current Informatics in Irish Limitations of current Informatics in Irish public mental health limited other mediums public mental health limited other mediums for data collectionfor data collection

Application of findings to larger Irish Application of findings to larger Irish mental health nursing populationmental health nursing population

Recommendations & further Recommendations & further researchresearch

In consultation with the local nursing In consultation with the local nursing practice development unit possible practice development unit possible development of enhancing knowledge in this development of enhancing knowledge in this area with current resources…area with current resources…

Undertake further analysis utilizing larger Undertake further analysis utilizing larger samples in varying regions…samples in varying regions…

Mixed method approaches to enhance the Mixed method approaches to enhance the richness of data…richness of data…

In summary..In summary..

The needs of needs of mental health The needs of needs of mental health services users should be identified through services users should be identified through research research (HSE, 2012)(HSE, 2012)

The development of physical health skills The development of physical health skills programmes should be specifically programmes should be specifically designed for mental health and mental designed for mental health and mental health practitionershealth practitioners (Woods, 2010).(Woods, 2010).

The End…The End…

Any Questions? Any Questions?

Author details: Author details: brendan.power1@hse.iebrendan.power1@hse.ie