can a mental health awareness programme increase the confidence of primary care nurses in managing...
TRANSCRIPT
Can a mental health awareness Can a mental health awareness programme increase the confidence of programme increase the confidence of
primary care nurses in managing primary care nurses in managing depression?depression?
Sally Gardner
Nurse Consultant OOH
Trainer /Facilitator Mental Health
DEPRESSIONDEPRESSION
Large Personal, Psychological and Economic Costs
Mental Health Problems = £32 BillionLost Employment = £12 Billion &
Productivity91 Million working days lostTreatment costs = £4.2 Billion
Diminished Quality of LifeExcessive use of Medical Services1 of the 4 most disabling illnesses in the
worldPrimary Care cares for 90% of these
Patients1 Patient in every surgery session suffering
from Depression
Some of the facts:Some of the facts: Depression is common and treatable GPs and nurses are at the “front line” Only 50% is acknowledged Depression is treatable with both drug and non-drug approaches Simply acknowledging depression improves the outcome Over 5000 people commit suicide each year in England …. 1 every 2 hours 9 out of 10 people who commit suicide have some form of mental illness …..
Mostly depression Suicide is 3 times more likely in men than women 66% of people who commit suicide have consulted their doctor within the
past month …. 30% have expressed intent 1 in 20 adults suffer from depression Psychotropic medication is the commonest and highest costing medication
MAJOR DEPRESSIONMAJOR DEPRESSION
Depressed mood and loss of interest and pleasure, plus 4 or more of the following:
Feelings of worthlessness or guiltImpaired concentration
Loss of energy or fatigueThoughts of suicide
Loss or increase in appetiteInsomnia or hypersomniaRetardation or agitation
…… for a minimum of 2 week’s duration
Depressed mood and loss of interest and pleasure, plus 4 or more of the following:
Feelings of worthlessness or guiltImpaired concentration
Loss of energy or fatigueThoughts of suicide
Loss or increase in appetiteInsomnia or hypersomniaRetardation or agitation
…… for a minimum of 2 week’s duration
How common?How common?
Diagnosis Rates per year Practice incidence
Schizophrenia 2-6 4-12 Affective Psychosis
3 6-7
Depression 30-50 60-100 Anxiety 35 70-80 Adjustment 27 50-60 Drugs/Alcohol 2.7 5-6
The Scale of the ProblemThe Scale of the Problem
General population
Consulting GP
Detected by GP
OP
IP
230-315/1000
230 / 1000
100 / 1000
20 / 1000
3 / 1000
THE SIZE OF THE PROBLEMTHE SIZE OF THE PROBLEM
What does this mean?What does this mean?
2.75 million people consult with their GPAverage GP practice of 2,000 pts 218 on
listPrimary care nurses ideally placed
Chronic Disease ManagementChronic Disease Management
AsthmaDiabetesVascular Disease
Depression and Anxiety?
The management of recognised cases of depression often falls short of best practice.
RationaleRationale
Developed mini clinicReduced referrals to CMHT – 60%
reductionBDI scores Mean = 23 at 4/12 Mean= 7
P=0.001High levels pt satisfactionGP workload shared
RationaleRationale
Funding soughtDeveloped training course (steering group) Audit & Evaluation demonstrated increased
knowledge and confidenceFurther evaluation needed
PCT TrainingPCT Training
Level 1 Epidemiology Recognition Medication Risk Assessment SEMI Health Promotion
Level 2,3 Clinical Governance Pharmacology Psychological
Therapies Nurse Intervention Setting up a Service
The StudyThe Study
Postal Questionnaire180 Primary Care NursesTwo Groups generated (training and No
training)Comparisons madeAnalysisOutcomes
AnalysisAnalysis Scales in questionnaire – Cronbachs alpha
Variables – MannWhitney U Test Confidence Attitude Satisfaction
Open ended questions Coded, themes developed and comparisons made
ParticipantsParticipants
0
10
20
30
40
50
60
0
10
20
30
40
50
60
No PCT Training PCT Training
Pe
rc
en
ta
ge
o
f
Pa
rt
ic
ip
a
Training
Comparisons of scoresComparisons of scores
0
10
20
30
40
50
60
70
0
10
20
30
40
50
60
70
Confidence Attitude Satisfaction
Me
an
R
an
k
of
S
co
re
Variable
No training PCT training
Comparisons of levels of Comparisons of levels of training 1 v 2&3training 1 v 2&3
0
5
10
15
20
25
0
5
10
15
20
25
Confidence Attitude Satisfaction
Me
an
R
an
k
of
S
co
re
s
Variable
level 1 level 2 + 3
ResultsResults
Response rate 47.8%Training group scored higher on
Confidence Attitude and Knowledge when compared to no training group
Level 1 training improved attitude but did not statistically increase knowledge or confidence when compared to level 2&3 training
QualitativeQualitative
51 comments were coded into positive, negative and neutral
50% were positive ( “training is greatly needed”)
35% were negative (“not sure short courses provide necessary skills”)
Neutral (“ protected time in short supply”)
Future Training Future Training
Interest in Training
strongly agree
agree
neutraldisagree
Training CoursesTraining Courses
0
10
20
30
40
50
60
70
0
10
20
30
40
50
60
70
half day full day lunchtime self-directed
Pe
rc
en
ta
ge
i
nd
ic
at
in
g
pr
ef
Training Format
Options regarding role of Options regarding role of nursesnurses
Role One – deliver enhanced recognition referral for assessment
Role two – deliver a service in the assessment and monitoring of patients with depression
Role three – development of depression mini clinics
What this study addsWhat this study adds• A training programme designed to increase confidence, improve attitudes towards depression and increase satisfaction with knowledge and training is effective
Primary care nurses are motivated to participate in future training in the management of depression.
Future courses should resemble the PCT training course
Depression “mini clinics” may require more organisation within primary care for them to be viable
Setting up a ServiceSetting up a Service
ProcessProcess
Involve the whole teamState clear AimWhat are the objectivesWhere are we nowWhere do we want to beHow do we know when we have got there
WhoWho
Who needs to be involved?
Who will referrals come from?
Who will have overall responsibility?
WhatWhat
What needs to be in place………Job descriptionProtocolsGuidelinesReferral guidelinesPatient pathwaysSupervision
Setting up a clinicSetting up a clinicLevel 1,2,3Level 1,2,3
Decide on service model
Level 1 – All members of team Mental health awareness Mental health Promotion G/P implements evidence based guidelines
Setting up a clinicSetting up a clinicLevel 2Level 2
Level 2 includes criteria from level 1 plus……
G/P diagnose a mental health problemRefers to Nurse clinicWorks collaboratively with G/P (case
reviews)
Setting up a clinicSetting up a clinicLevel 2Level 2
Telephone support 1-2 weeksNurse review 2-4 weeks Holistic assessmentNurse monitors mood and compliance to
medicationRisk assessment
Setting up a clinicSetting up a clinicLevel 3Level 3
Level 3 Includes criteria from level 1&2 plus
Identifies and differentially diagnose own patients Holistic assessment Arranges tests and investigations Diagnosis Decides on medical management Supplementary prescribing
Setting up a clinicSetting up a clinicLevel 3Level 3
Liase with other members teamCase ManagementAccountableResponsibleAutonomousRefersDischarge
ImplementationImplementation
Team meetingDecide on service modelSet realistic timescalesAudit trail in placeRegular reviews (team)Ongoing auditPatient satisfaction tools
EvaluationEvaluation
SWOT Analysis
Forcefield Analysis
Audit against standards
What needs to change??
Make changes
Implement and review
ConclusionConclusion
Primary Care Nurses have an important role in managing depression
Pilot study identified improved outcomesEvaluation study identified increased
satisfaction with knowledge confidence and attitude.
ConclusionConclusion
Training is effectiveTraining is requestedShort courses are the preferred optionThere are different options regarding
management of depressionThree models identified
ConclusionConclusion
Training primary care nurses in depression management and delivering a service in primary care is posssible
It can only be hypothesied that this will improve outcomes
There is a need for a RCT comparing patient outcomes delivered by nurses with training and usual primary care.
