Using consultancy to advance practice in liaison psychiatry

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Using consultancy to advance practice in liaison
psychiatry

• Anthony Harrison
• Consultant Nurse
• Research Fellow, Faculty of Health Social
  Care

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Liaison psychiatry

• General hospital psychiatry or psychological
  medicine
• Liaison psychiatry, mental health liaison and
  liaison nursing - used synonymously.
• Liaison nursing applied to the general hospital
  first used in the US in the 1960s (Jones, 1989).
• Liaison psychiatry as a speciality was developed
  in the US during the 1930s.

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• Following World War II, services in the US
  increased tenfold, with most growth occurring
  during the 1960s and 70s (Morriss Mayou, 1996).
• In the UK, tentative developments took place in
  the 1960s, but it was the development of
  community care in the late 1970s that signified
  the biggest development.
• Decriminalisation of suicide in 1961 an impetus
  to focus on mental health in the general hospital.

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Development of liaison nursing

• Influence of the work of Hildegard Peplau (1994).
• Peplau importance of a therapeutic relationship
  with the patient, attaches equal importance to
  physical and psychological domains, holistic in
  nature, relevant to all branches/specialisms of
  nursing.
• Pre-dates development of liaison nursing roles in
  the late 1980s and 1990s.

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Liaison nursing in the UK

• Working in Partnership (DoH, 1994) formal
  recognition of the potential role for mental
  health nursing in the care of people within
  physical healthcare settings.
• Jones (1989) and Tunmore (1990) described early
  examples of the role.
• During 1990s, focus was on self-harm and suicide
  prevention working within emergency departments
  (EDs).

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Other influences

• Suicide prevention national strategies
  England, Wales, Scotland Northern Ireland
  currently being developed.
• Recommendations from Royal College of
  Psychiatrists/Physicians (1995 2003).
• National Service Frameworks eg mental health
  (1999) self-harm, cancer, Essence of Care (2001
  2003).
• Target culture Patients Charter, waiting
  times, payment by results

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Problems

• Lack of co-ordinated service development and
  education nursing roles and posts developed
  ahead of educational opportunities.
• Poor service planning and commissioning.
• Whose responsibility mental health services,
  acute (general hospitals)?
• Co-existing development of crisis and home
  treatment services clash or conflict in roles?

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Distinctions between crisis teams and liaison
teams
Crisis Team
Complementary Liaison team
General hospital based Provision of
hospital-based treatment and care Non-urgent
assessment of acute presentations Facilitation of
general hospital staff to address mental health
problems Broad referral criteria

• Urgent risk assessment and management
• Medication management
• Mental health promotion
• Education and training
• Advice and support to other health care
  professionals

Community-based Provision of home-based
treatments and care Urgent assessment of acute
presentations Facilitates timely discharge from
psychiatric units Alternative to psychiatric
admission Narrow referral criteria
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Consultancy and the development of liaison roles
and services

• Components of higher level practice (UKCC, 1998)
• Providing effective health care.
• Improving quality health outcomes
• Evaluation and research.
• Leading developing practice.
• Innovation changing practice.
• Developing self and others.
• Working across traditional boundaries.

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Roles of the advanced practitioner

• Manley (1997)
• Expert in his/her field.
• Educator peers/patients/relatives/colleagues
• Consultant eg client-centred case
  consultation, consultee-centred case consultation
  Caplan (1964).

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Skills of the Expert Practitioner

• Transformational leadership style eg
  strategist, visionary, catalyst.
• Skills in
• Collaboration
• Change management
• Role modelling
• Facilitation staff development, practice
  development, organisational development.

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Model of skills brought into practice
Technical
Critical Thinking
Interpersonal relationships
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Pre-requisites for advanced practice

• Shared values and beliefs.
• Open, non-hierarchical management.
• Organisational authority attributable to your
  post.
• Whole systems thinking how will this post and
  what you do fit into the wider practice,
  organisational, managerial, professional agendas?

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Hows of advancing practice

• Not always about extending/expanding the role
  just as important to define and advance the role.
• Applying and integrating all aspects of
  knowledge.
• Having skills to make links between knowledge
  rather than being all-knowing a strategic
  overview.
• High level of skill.
• Advocacy and dignity.
• New, risky, possibly things that havent been
  done by your professional group before.

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Outputs from advanced practice

• Developed and empowered staff.
• Client-centred developments in professional
  practice.
• A transformational culture.
• QUALITY CLINICAL SERVICES

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Reality check

• Conflict and change are endemic there are some
  things that you just cant do much about.
• Decision-making is not always a rational nor an
  orderly process.
• There will always be conflicting demands.
• Uncertainty is a way of life.
• Bias exists and is a reality.
• External forces have an impact.

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Survival tips

• Choose the problems to work on.
• Develop a very broad and detailed knowledge of
  the organisation, its people and its drivers.
• Develop an awareness of your own strengths and
  weaknesses.
• Develop your own skills to better influence
  others.
• Seek and use mentors and critical companions

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• NEVER
• Say something cant be done.
• Underestimate the power of teamwork
• Get complacent.
• Walk away from tough decisions.
• Stop listening, questioning and innovating.
• Be afraid to take risks.

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Reflection

• How ready are you to develop or move into the
  field of advanced practice?
• What support/help do you need to develop an
  advanced practice role? Consider educational
  preparation, organisational structure, models of
  service delivery, internal and external support.
• How do you think developing advanced practice
  roles will enhance the patient experience?

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References

• Astbury-Ward, E. (2000) Practising at a higher
  level. Nursing Standard 14 (47) 14-15.
• Cox, C.L. (2000) The nurse consultant an
  advanced nurse practitioner? Nursing Times 96
  (13) 48.
• Castledine, G., McGee, P. (1998) Advanced
  Specialist Nursing Practice. Oxford Blackwell
  Science.
• Manley, K. (2000) Organisational culture and
  consultant nurse outcomes part 1 organisational
  culture. Nursing Standard 14 (36) 34-38.

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• Manley, K. (2000) Organisational culture and
  consultant nurse outcomes part 2 nurse outcomes.
  Nursing Standard 14 (37) 34-38.
• Manley, K. (1997) A conceptual framework for
  advanced practice an action research project
  operationalizing an advanced practitioner/consulta
  nt nurse role. Journal of Clinical Nursing 6
  179-190.
• Sutton, F., Smith, C. (1995) Advanced nursing
  practice new ideas and new perspectives. Journal
  of Advanced Nursing 21 1037-1043.

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Contact details

• anthony.harrison_at_uwe.ac.uk