By Watson, Emily
ABSTRACT
Increasing numbers of children and young people with mental health problems are being cared for in general paediatric settings, presenting a challenge to nurses who do not have mental health nursing qualification and experience. A survey of nurses in a children’s hospital identified their concerns and attitudes to caring for this client group. On-call nursing support was felt by almost all nurses (87 per cent, n=90) to be the most beneficial aspect of a liaison service, followed by teaching (84 per cent) and individual support with the young person/family (84 per cent). Based on the findings, a project was initiated to improve nursing liaison with CAMHS nurses providing support and advice to general children’s nurses. Effective liaison between general paediatric wards and child and adolescent mental health services (CAMHS) can improve care for children and young people with diagnosed mental health problems. However, there is still a gap in addressing the need of the significant numbers of children with physical illness who also have mental health needs.
KEY WORDS
CAMHS
Liaison roles
Children: services
Child and adolescent mental health is a sub-speciality of both mental health and paediatrics. The disparity between these two fields has sometimes delayed development of child and adolescent mental health services (CAMHS). Liaison between mental health and general services (both in adult and paediatric settings) can be challenging and is often unplanned and unmanaged (Benjamin et al 1994, Anders 1997, Black et al 1990).
The need for a robust model of liaison is recognised, but collaborative working between professionals is not always evident (Tipper and Moon 2001). A multi-disciplinary framework is thought to be the most effective working model for liaison; commitment from professionals in paediatric, psychiatric and psychological disciplines are essential to its success (Williams and Wright 2003, Lask 1994).
At Birmingham Children’s Hospital the psychiatry and psychology departments already had a fully functional liaison service but a need was identified for improved nursing liaison. This article reports on a project to develop more effective liaison between CAMHS nurses and nurses working in general wards.
Service context
More children and young people are presenting to A&E departments with self-harm and being admitting with other conditions such as psychosomatic problems, eating disorders and psychosis. The number being accommodated on general paediatric wards and adolescent units is therefore increasing. Inpatient CAMHS provision has yet to catch up with the now widespread recognition of this increased need. Fortunately, the mental health needs of children and young people have been given a high priority in recent health policy (DH 2004). Provision of collaborative evidenced-based mental health care for children and young people, irrespective of clinical environment, has been identified as a role for all nurses (RCN 2004).
The CAMHS nursing role is often very specific and can add a dimension to the care of children and adolescents with mental health problems which other disciplines may not have the time, resources or skills to deliver. Liaison nursing focuses on the interpersonal relationship between nurses and patients rather than on diagnosis and treatment of illness (Robinson 1987). Nurses in a CAMHS liaison role provide clinical care, consultation, supervision, education, and undertake research (Tunmore and Thomas 1992). Crucially, they provide support and advice to nursing colleagues in the general paediatric setting who have 24-hour responsibility for the wellbeing and safety of this client group. Recognising that these nurses are providing care in a less than perfect clinical environment is key to building effective partnerships within liaison, as is acknowledging the challenges of caring for troubled adolescents in a paediatric ward or emergency department.
Exploring concerns
Possible objectives for a CAMHS liaison service were identified through discussion with staff in existing liaison services and feedback from senior nurses within both paediatric and mental health environments (Box 1). This initial exercise reflected an idealised view of the type of service that might be established within Birmingham Children’s Hospital. It was important to explore the real concerns and needs of nurses rather than base developments on our perception of the shortfall in service provision. Anecdotally, nurses seemed to feel frustrated and were reluctant to provide care for this patient group. There seemed to be confusion about the services provided within CAMHS, as the comments from three children’s nurses demonstrate:
‘If I’d had wanted to “do” mental health I would have been a mental health nurse’
“The doctor said we have to feed the girl continuously through the night as we need her weight to increase ready for discharge’
“The CPN (Community Psychiatric Nurse) will talk to her about why she took the overdose, its best we don’t get involved’
To identify nurses’ actual attitudes and concerns, a questionnaire was developed and piloted and then distributed to nurses working in a number of paediatric environments in the trust. Specialist units, such as infant care, day care, theatres, intensive care and oncology, were excluded. The areas covered in the questionnaire included: how much contact the nurses had with young people with mental health problems, the training they had received, their anxieties and attitudes towards caring for this client group and the amount and type of support they would like from the liaison service.
Results
Two hundred questionnaires were distributed and 90 returned, a 45 per cent response rate. Sixty four per cent of those who responded said they nursed this client group in their clinical area, and 79 per cent stated that they did not feel experienced in meeting the needs of young people with mental health problems. These figures suggest that there is a lack of experience and evidence-based knowledge in the care of this client group. Most respondents (88 per cent) felt that training in mental health issues is needed for all nurses in paediatric settings. Universities include child and adolescent mental health nursing in pre-registration children’s nursing courses, but this provision is not reflected in the training and development of qualified nursing staff (Hooton 1999, RCN 2003).
Interestingly, 58 per cent of these nurses felt that mental health nurses should be included in the staffing of paediatric wards, suggesting either that other nurses would benefit from the constant presence of mental health nurses, or that they see caring for this client group as someone else’s role.
Box 1 Objectives of a Nursing Liaison Service at Birmingham Children’s Hospital NHS Trust
Table 1. Areas of support considered beneficial within a mental health nursing liaison package (n=90)
Nurses appeared to have little knowledge of CAMHS provision. They seemed to think there was a lack of ‘beds’ and specialist CAMHS staff to meet the needs of these patients. Most (84 per cent) agreed that this is what frustrated them indicating a need to raise awareness about CAMHS structure, input, roles and assessment procedures throughout the trust. This lack of awareness may explain why the majority of respondents felt the trust does not do enough for this client group.
When asked about what support their clinical area receives, 67 per cent reported little or no support from mental health professionals. Almost all (90 per cent) felt that all young people with a diagnosed mental health condition should receive assessment and individual support from mental health professionals. This, at present unrealistic, expectation raises the question of who should deliver care and how we should move towards this practice.
These results gave some insight into the attitudes and feelings of nurses in one acute paediatric trust. A gap in support for patients and staff in non-CAMHS areas was clearly identified and the nurses were able to identify what they would find useful in a programme of liaison (Table 1). On-call nursing support was most frequently rated as a beneficial aspect of liaison (87 per cent), followed by teaching on conditions and management approaches (84 per cent), and individual support with the young person/family (78 per cent).
Outcomes
Education and collaboration
Once the liaison service was initiated, the biggest component quickly became teaching and education. Wards and departments scheduled sessions on a range of mental health conditions and approaches as the project unfolded. General adolescent areas, trauma and orthopedic wards and the A&E department received regular sessions on self-harm, attention deficit hyperactivity disorder, eating disorders and psychosis. Nurses in these fields demonstrated a commitment and awareness of their educational needs that was encouraging and helped to develop a greater sense of collaborative working between themselves and the project liaison nurse. The informal nature of the sessions led to confidential case discussions allowing for practical challenges to be explored and real-life concerns to be aired.
A one-day study event that soon extended to a twoday programme enabled paediatric nursing colleagues to become better informed on the holistic aspects of mental health care. The involvement of hospital teaching colleagues, play services, ne\wly qualified CAMHS inpatient nurses and interest from other professions led to a multi- professional/multi-agency study programme. This enables professionals working with child and adolescent mental health patients within the trust to discuss together optimum care approaches and gain better understanding of each other’s roles and limitations in managing this patient group.
Consultation and support
A record was kept of the varying problems of children and young people for whom CAMHS nursing consultation/support was requested over the 18-month period. (Figure 1). Referrals for nursing consultation came from two sources: consultant liaison psychiatry and children’s nurses. The total number of requests over the 18 month period was 62 and although this figure may seem low, the liaison service was only provided once a week and by one clinician. This figure does not reflect other sources of support from psychiatry and psychology services, community mental health professionals and others such as dietitians and physiotherapists giving guidance and reassurance within a holistic package of care.
The most significant outcome of the programme was increased awareness of mental health issues and the informal discussions generated within paediatric environments. This culminated in the formation of a mental health interest group by children’s nurses in the trust. Informal feedback indicated that nurses were liberated by being able to contact their CAMHS colleagues for telephone advice and guidance; they were able to question their current or traditional practices. Armed with evidence-based material, nurses were more confident in challenging approaches and attitudes of paediatricians and other disciplines as they established new working practices and methods for care delivery.
Conclusions and challenges
This project provided the opportunity for greater collaboration between paediatric and CAMHS nursing colleagues in caring for the mental health needs of young people in non-CAMHS areas. The overall response to the project was extremely positive from both nursing colleagues and professionals already involved in psychiatric/ paediatric liaison. Nurses reported gaining new knowledge on the signs and symptoms of a range of mental health conditions and felt better equipped in the management of this client group. Several wards now receive regular teaching sessions and updates. Nursing staff have also provided feedback on the benefits of increasing links between ward areas and CAMHS. Developing care plans from both a general children’s nursing and a CAMHS nursing perspective has reportedly enhanced the individualised holistic care of patients. It has also enlightened CAMHS nursing staff about the challenges faced by nurses in nonCAMHS areas.
While this project identified the need for mental health nursing liaison for young people presenting with a diagnosable mental health condition, it did not address the needs of the large number of young people who experience such difficulties alongside a physical illness. Approximately a half of all paediatric outpatient attendees have conditions in which psychological factors are a major factor (Lask 1994). Children’s nurses caring for such children need to be aware of their mental health needs, and mental health professionals require the same awareness of the physical components of illness to ensure they offer an integrated, seamless service (Williams and Wright 2003).
A firm commitment to collaborative working between CAMHS and other ward areas has been demonstrated in the interest shown in developing guidelines and core care plans together for a variety of mental health conditions. The CAMHS inpatient unit on-site now provides respite and emergency action for young people located on other wards. This practical intervention further encourages the development of liaison and generates a positive relationship between CAMHS and general paediatrics. However, to sustain a long lasting and valuable relationship and move from a project to standard permanent practice requires resources, effort and enthusiasm.
Figure 1 Conditions for which consultations were requested (n=62)
Clinical governance also needs to be recognised as an essential force in promoting the effective care of young people with mental health problems in general paediatric settings. Risk assessments in support of evidenced-based care approaches will go some way to ensuring a safer environment for this patient group and to reassure patients, families and professionals that the area has been adapted to promote the safety of the young person.
It is not enough to state that young people, for example with extreme confusion, psychotic presentations or eating disorders, are CAMHS patients and as such will just be maintained in paediatric environments using whatever approaches come to mind. The reality is that increasing numbers of young people with a variety of mental health problems will be placed in a range of paediatric settings. They are entitled to be cared for by health and social care professionals who are competent to address their mental health needs with early intervention and assessments and with the support of effective liaison between paediatrics and psychiatry
ACKNOWLEDGEMENTS
Ray McMorrow, Nurse Consultant, CAMHS, Birmingham Children’s Hospital NHS Trust.
Ward 3 Nursing and Medical Teams, CAMHS, Birmingham Children’s Hospital NHS Trust.
Wards 5,7,8,9,12 and A&E, Birmingham Children’s Hospital NHS Trust.
The number of children with mental health conditions being accommodated on general paediatric wards and adolescent units is increasing
REFERENCES
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Hooton S (1999) Results of a survey undertaken to establish the degree to which post registration programmes address child and adolescent mental health. London, ENB.
Lask B (1994) Paediatric liaison work. In Rutter M et al (eds) Child and Adolescent Psychiatry: Modem Approaches. Oxford, Blackwell.
DH (2004) The National Service Framework for Children, Young People and Maternity Services. London, Department of Health.
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Royal College of Nursing (2003) The post-registration education and training needs of nurses working with children and young people with mental health problems in the UK. London, RCN.
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Tunmore R, Thomas B (1992) Models of psychiatric consultation liaison nursing. British Journal of Nursing. 1, 9, 447-451.
Williams C, Wright B (2003) Paediatric liaison. In Richardson G, Partridge I (eds) Child and Adolescent Mental Health Services, An Operational Handbook. London, Royal College of Psychiatrists.
Emily Watson RN, BSc is children’s service manager, Barnado’s, Tamworth. At time of writing she was professional development facilitator (CAMHS) Birmingham Children’s Hospital NHS Trust
Copyright RCN Publishing Company Ltd. Feb 2006
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