Can a mental health awareness programme increase the confidence of primary care nurses in managing d

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Can a mental health awareness programme increase
the confidence of primary care nurses in managing
depression?

• Sally Gardner
• Nurse Consultant OOH
• Trainer /Facilitator Mental Health

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DEPRESSION

• Large Personal, Psychological and Economic Costs
• Mental Health Problems 32 Billion
• Lost Employment 12 Billion Productivity
• 91 Million working days lost
• Treatment costs 4.2 Billion

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• Diminished Quality of Life
• Excessive use of Medical Services
• 1 of the 4 most disabling illnesses in the world
• Primary Care cares for 90 of these Patients
• 1 Patient in every surgery session suffering from
  Depression

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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

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MAJOR DEPRESSION
Depressed mood and loss of interest and pleasure,
plus 4 or more of the following Feelings of
worthlessness or guilt Impaired
concentration Loss of energy or fatigue Thoughts
of suicide Loss or increase in appetite Insomnia
or hypersomnia Retardation or agitation for a
minimum of 2 weeks duration
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How common?
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The Scale of the Problem
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What does this mean?

• 2.75 million people consult with their GP
• Average GP practice of 2,000 pts 218 on list
• Primary care nurses ideally placed

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Chronic Disease Management

• Asthma
• Diabetes
• Vascular Disease
• Depression and Anxiety?

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• The management of recognised cases of depression
  often falls short of best practice.

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Rationale

• Developed mini clinic
• Reduced referrals to CMHT 60 reduction
• BDI scores Mean 23 at 4/12 Mean 7 P0.001
• High levels pt satisfaction
• GP workload shared

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Rationale

• Funding sought
• Developed training course (steering group)
• Audit Evaluation demonstrated increased
  knowledge and confidence
• Further evaluation needed

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PCT 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

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The Study

• Postal Questionnaire
• 180 Primary Care Nurses
• Two Groups generated (training and No training)
• Comparisons made
• Analysis
• Outcomes

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Analysis

• Scales in questionnaire Cronbachs alpha
• Variables MannWhitney U Test
• Confidence
• Attitude
• Satisfaction
• Open ended questions
• Coded, themes developed and comparisons made

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Participants
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Comparisons of scores
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Comparisons of levels of training 1 v 23
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Results

• 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 23 training

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Qualitative

• 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)

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Future Training
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Training Courses
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Options regarding role of nurses

• 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

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What 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

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Setting up a Service
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Process

• Involve the whole team
• State clear Aim
• What are the objectives
• Where are we now
• Where do we want to be
• How do we know when we have got there

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Who

• Who needs to be involved?
• Who will referrals come from?
• Who will have overall responsibility?

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What

• What needs to be in place
• Job description
• Protocols
• Guidelines
• Referral guidelines
• Patient pathways
• Supervision

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Setting up a clinicLevel 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

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Setting up a clinicLevel 2

• Level 2 includes criteria from level 1 plus
• G/P diagnose a mental health problem
• Refers to Nurse clinic
• Works collaboratively with G/P (case reviews)

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Setting up a clinicLevel 2

• Telephone support 1-2 weeks
• Nurse review 2-4 weeks
• Holistic assessment
• Nurse monitors mood and compliance to medication
• Risk assessment

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Setting up a clinicLevel 3

• Level 3
• Includes criteria from level 12 plus
• Identifies and differentially diagnose own
  patients
• Holistic assessment
• Arranges tests and investigations
• Diagnosis
• Decides on medical management
• Supplementary prescribing

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Setting up a clinicLevel 3

• Liase with other members team
• Case Management
• Accountable
• Responsible
• Autonomous
• Refers
• Discharge

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Implementation

• Team meeting
• Decide on service model
• Set realistic timescales
• Audit trail in place
• Regular reviews (team)
• Ongoing audit
• Patient satisfaction tools

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Evaluation

• SWOT Analysis
• Forcefield Analysis
• Audit against standards
• What needs to change??
• Make changes
• Implement and review

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Conclusion

• Primary Care Nurses have an important role in
  managing depression
• Pilot study identified improved outcomes
• Evaluation study identified increased
  satisfaction with knowledge confidence and
  attitude.

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Conclusion

• Training is effective
• Training is requested
• Short courses are the preferred option
• There are different options regarding management
  of depression
• Three models identified

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Conclusion

• 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.

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THANKYOU

• QUESTIONS ?
• Sally Gardner
• Nurse Consultant
• Take Care Now
• Sally.gardner_at_takecarenow.co.uk