Primary Care: Do we need to reinvent Psychiatric Nursing

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Primary Care Do we need to reinvent
Psychiatric Nursing?

• Prof Seamus Cowman
• Royal College of Surgeons in Ireland
• Mental Health Nurse Managers Ireland
• Annual Conference May 2004

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Service Provision
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Into Primary Care

• Nightingale said
• Nursing should be practised wherever it is
  needed.
• Question
• Why have the policy makers and professions
  adopted an institutional model of service
  delivery? (almost exclusively)

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Constraints on Psychiatric Nursing

• Psychiatric nursing has continued to be dominated
  by therapeutic shifts that taken place within the
  discipline of psychiatry and this has led to an
  inevitable sense of role confusion in psychiatric
  nursing, together with the resultant lack of
  power that such confusion generates (Nolan 1993)
  

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Constraints on Psychiatric Nursing

• Imposed segregation
• Social order within asylum, hierarchy in
  operation with RMS at the top
• The lack of exposition of good nursing care
  practices of the caring, productive and
  therapeutically beneficial relationships.

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Psychiatry

• Opening Skinners Box Great Psychological
  Experiments of the Twentieth Century.
• Lauren Slater, Bloomsbury.

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ICU OR SECLUSION OR BOTH

• 28.5 of psychiatric facilities had access to
  both an ICU and a seclusion room
• 20 of psychiatric facilities neither had access
  to an ICU or a seclusion room.

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Psychiatric Nursing

• As Psychiatric nurses we know what nursing is and
  what it has always been. The problem is that
  nurses did not pay enough attention to defining,
  describing, strengthening and leading psychiatric
  nursing out of its traditional existence.

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What people said about ...
People with mental health difficulties
More GP involvement
Specialist support in the community setting
Support and follow- up after discharge and in
move from long stay to community setting
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Primary Care A New Direction
Putting patients and clients at the centre by
integrating services
Right care, in the right place at the right time
Enhanced the capacity of health services
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Into Primary Care

• Mental Health Commission
• Mental health services should be community based
  providing a range of specialised
  multi-disciplinary community mental health teams.

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Into Primary Care

• John Saunders CEO Schizophrenia Ireland
• High rate of involuntary admission to psychiatric
  units.
• If the necessary back-up was provided to families
  in the first place, many of these involuntary
  admissions would never need to be made.

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Into Primary Care

• Mr Enda Egan CEO Carers Association
• Decreased funding in mental health services had
  largely gone unnoticed

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Into Primary Care

• Mr Enda Egan CEO Carers Association
• Care provided by families must be seen as an
  investment in the future. The Dept of Finance
  have to see that investment in family carers will
  save money in the long run.
• Mrs Tessa Woods V (Southern Health Board)
• The health board was prepared to pay for care
  five days a week in a centre yet they did not
  want to pay for care in the home

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Primary Care (Psychiatry)
Evidence
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Primary Care Team
Interdisciplinary - team based
Membership
Population 3,000 - 7,000
Implementation Projects
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Integration of Primary and Secondary Care
Co-ordination
Information communication technology
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Primary Care System

• Prioritises early recognition of disorder,
  provision of the appropriate mix of primary care
  and specialist services at the appropriate point
  in the illness, course, the appropriate mix of
  pharmacological and non pharmacological
  interventions, active tracking, consumer support
  and outcome measurement.
• (Tummy R. 2001)

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Into Primary Care

• In USA 3 key actions
• Education of Primary Care Staff
• Locating specialist providers in primary care to
  provide treatment
• Consultation/liaison where clients are managed by
  primary care professionals who are themselves
  supported by specialist staff

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Into Primary Care

• Primary Care. A New Direction
• (DOHC 2001)
• Articulates a vision that goes beyond general
  practice to encompass a wide range of health and
  social services delivered by a range of
  professionals.

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Into Primary Care

• Organisation of Community Nursing Need for
  change in structures, processes in line with
  expansion of Primary Care.
• A requirement for interdisciplinary teams.
• (Primary Care. A New Direction)
• (DOHC 2001)

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Into Primary Care

• CPNs in Primary care
• GPs were consistent in their view that CPNs have
  a key role to play in and are cost effective and
  skilled in the management of a range of mental
  health problems.
• Brought mental health awareness to team and
  assisted them with the acquisition of skills to
  enable early recognition and treatment of mental
  health problems.
• Badger F., Nolan P. (1999) Journal of Psychiatric
  Mental Health Nursing 6(6), 453 - 459

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Primary Care

• A Strategy for Community Nursing?

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Into Primary Care

• Primary Care teams
• Groups do not become teams
• Team work job satisfaction, lower levels of
  stress and burnout,
• ? retention.
• Nurses who worked well in teams demonstrated
  greater autonomy involvement in decision
  making.
• (Rafferty 2001 International Hospital Outcomes
  Study)

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Primary Care

• The challenges of team collaboration
• Poor identification of skills
• Professional identity and role ambiguity
• Inequitable workloads
• Status disparity
• Confusion with accountability
• Vested interests
• Struggles with power and authority.
• (Carryer et al 1999)

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Into Primary Care

• To what extent have psychiatric nurses
  established a strategic presence in mental
  health.
• Is primary care the opportunity for psychiatric
  nurses to provide leadership in mental health
  services?

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Into Primary Care

• Role of the Psychiatric Nurse
• Assessing patient needs and evaluating care
• Planning Care
• Nurse/patient caring interactions
• Pharmaceutical interventions
• Education
• Documenting information
• Co-ordinating the services of nurses and other
  professionals
• Communication with other professionals and other
  grades of staff
• Administration and organisation of the clinical
  area
• Cowman 2001 Jnr Advanced Nursing 34 (6), 745
  753.

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Psychiatric Nursing Education

• Provide for new knowledge and skills related to
• Practice Development
• Therapeutic roles Nurse Prescribing
• Assessment Skills
• Team Work
• Communications, verbal, written, IT
• Audit and Research skills
• Leadership
• Entrepreneurialism

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Psychiatric Nursing Education

• Declare a position
• Establish a Strategy Group and plan areas for
  development Specialist and Advanced Practitioners
  in Psychiatric Nursing.
• Liaison Psychiatric Nurse
• ????
• ????
• Interdisciplinary components as much as possible

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• .

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Psychiatric Nurses and Primary Care

• The greatest danger for most is not that our aim
  is too high and we miss it, but it is too low and
  we reach it.
• (Tom Peters quoting Michelangelo)