Evaluating mental health nurses’ confidence in recognising a physically deteriorating patient
Intended for healthcare professionals
Evidence and practice    

Evaluating mental health nurses’ confidence in recognising a physically deteriorating patient

Marie King Student Allocations and Clinical Placement Coordinator, Nurse Education Centre, St Patrick’s Mental Health Services, Dublin, Republic of Ireland
Brian Keogh Assistant Professor, School of Nursing and Midwifery, Trinity College Dublin, University of Dublin, Dublin, Republic of Ireland
Gráinne Donohue Research Fellow, School of Nursing and Midwifery, Trinity College Dublin, University of Dublin, Dublin, Republic of Ireland

Why you should read this article:
  • To familiarise yourself with the importance of recognising the signs and symptoms of a deteriorating patient in mental health settings

  • To learn how using an Early Warning Score can support nurses to recognise when patients are deteriorating

  • To understand how to improve the confidence of mental health nurses in recognising deteriorating patients

Background People who experience serious mental health issues are at an elevated risk of premature death. Research demonstrates that serious adverse events in mental health settings can be avoided through the recognition and appropriate response to early signs of physiological deterioration.

Aim To evaluate the self-reported confidence of mental health nurses in recognising physically deteriorating patients in a mental health setting.

Method This pilot study used a quantitative survey to capture 22 mental health nurses’ confidence in clinical decision-making before and after an educational workshop using the National Early Warning Score (NEWS). Participants were requested to make clinical decisions about the management of two case studies (patient A and patient B). The NEWS workshop was piloted in a ward for older people with mental health issues.

Results Mental health nurses’ levels of confidence in managing physically deteriorating patients improved after the NEWS workshop.

Conclusion Following the implementation of a NEWS workshop, mental health nurses demonstrated improved confidence in clinical decision-making about physically deteriorating patients, albeit in an educational setting.

Mental Health Practice. doi: 10.7748/mhp.2020.e1519

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

@DonohueGrainne

Correspondence

donohuga@tcd.ie

Conflict of interest

None declared

King M, Keogh B, Donohue G (2020) Evaluating mental health nurses’ confidence in recognising a physically deteriorating patient. Mental Health Practice. doi: 10.7748/mhp.2020.e1519

Published online: 24 November 2020

Background

It is well recognised that people who experience serious mental health issues are at an elevated risk of premature death (Shaddel et al 2014). Specifically, people with a diagnosis of schizophrenia and bipolar affective disorder have higher rates of stroke, heart disease, hypertension and diabetes compared with the general population (Nash 2010). This is compounded by people with serious mental health issues being more likely to have lower survival rates from these co-morbid physical conditions than those in the general population, and being more likely to die at a younger age (de Hert et al 2011). People with mental health issues often experience acute physical health issues when they are admitted to psychiatric hospitals (Jones et al 2008). Some inpatients are exposed to interventions or substances such as physical restraint or rapid tranquilisation that can contribute to a rapid deterioration in physical health (Nash et al 2015). Furthermore, issues such as diagnostic overshadowing and a lack of confidence among mental health nurses in managing physical health issues can compromise the physical healthcare of people with mental health issues (Nash 2014). Mental health nurses caring for people in inpatient and community settings therefore require skills to manage their co-morbid physical health conditions. This requires a more integrated system of physical and mental healthcare than that presently available (Firth et al 2019).

Mental health nursing and physical healthcare

Research has shown that serious adverse events in mental health settings can be avoided through the recognition and appropriate response to early signs of physiological deterioration (Prytherch et al 2010). However, due to a perceived lack of competence propagated by the absence of undergraduate or postgraduate training in physical health, many mental health nurses fail to provide adequate physical healthcare (Nash 2010, Howard and Gamble 2011, Ramluggun et al 2017). Additionally, compared with their role in mental healthcare, mental health nurses are less likely to value their role in the provision of physical healthcare (Brimblecombe et al 2007).

In the absence of a formal educational module in physical healthcare, mental health nurses may lack the physical healthcare skills required to screen, provide interventions and support patients (Taylor and Shiers 2016). Despite this, studies have indicated that mental health nurses demonstrate a desire to engage with a physical healthcare role (Mwebe 2017), and have sought additional training in this domain (Çelik Ince et al 2018). In a UK study, Robson et al (2013) found that mental health nurses felt more equipped to take on a more prominent role in the physical healthcare of patients after completing an educational module. In this sense, increasing the physical healthcare knowledge of mental health nurses may contribute to a reduction in gaps in practice, and thereby decrease the healthcare inequalities experienced by people with mental health issues (Hemingway et al 2015).

Due to co-morbid physical conditions among their patient population, the capacity of mental health nurses to provide routine physical healthcare has become a research priority (Hennessy and Cocoman 2018). Studies that investigate methods of increasing mental health nurses’ confidence in physical healthcare are essential to ensure that optimal practice is provided in mental healthcare settings.

Early Warning Score

To assist in the early detection of critical incidents, many hospitals now use a ‘track and trigger’ system called an Early Warning Score (EWS) (Morgan et al 1997). An EWS is a simple scoring system based on careful routine physiological measurement of a patient’s heart rate, blood pressure, respiratory rate, temperature and level of consciousness. Scores of 0-3 points are allocated to these measurements from which a total score is calculated and an algorithm used to direct the clinician towards the appropriate course of action.

Since Morgan et al (1997) designed the EWS, more than 100 algorithms of this type have been implemented globally across various healthcare settings. The introduction of an EWS can assist mental health nurses to recognise individuals whose physical health is deteriorating and adopt the most appropriate response. In theory, this will ensure the early detection of deteriorating patients, promote early intervention and avoid unnecessary negative outcomes ranging from emergency department admission to death (Prytherch et al 2010).

A Modified EWS (MEWS) system that was designed to assess deterioration in physical health in people with mental health issues has been used in some mental health settings (Aligawesa and Marks-Maran 2017). However, because there is little evidence evaluating the effectiveness of MEWS, the National Early Warning Score (NEWS) was considered the most suitable tool to be piloted in the mental health setting featured in this study. Developed by the Royal College of Physicians (RCP) in 2012, NEWS is a track and trigger system designed to calculate a total EWS from routinely collected observations. This overall score can indicate early signs of deterioration in patients’ conditions and prompt more timely medical review and treatment. NEWS was implemented across Irish healthcare settings in response to a policy initiative and patient safety programme in the Irish Health Service Executive (Health Service Executive (HSE) 2011). Since this study took place, a more up-to-date version of NEWS – NEWS2 – has been released in the UK (RCP 2017).

To support the implementation of NEWS detailed in this study, a brief educational NEWS workshop was designed and delivered to mental health nurses, alongside completion of a pre- and post-evaluation survey. This article presents the results from the evaluation, which sought to assess the effects of the NEWS workshop on the self-confidence of mental health nurses in recognising physically deteriorating patients.

Aim

To evaluate the self-reported confidence of mental health nurses in recognising physically deteriorating patients in a mental health setting.

Method

This study used a quantitative survey to capture nurses’ confidence in clinical decision-making before and after attending an educational NEWS workshop. The participants of this pilot study were asked to make clinical decisions concerning the management of two case studies: patient A and patient B. The case studies were adapted from Shaddel et al (2014) and designed to assess confidence in decision-making when caring for a physically deteriorating patient (Figure 1). Participants were asked what clinical steps they would implement for the case study patients A and B, who were the same age and gender, with specific clinical parameters (Figure 1). The participants’ scores were then compared before and after the NEWS workshop. According to NEWS, the correct decision for patient A was ‘continue as usual’; for patient B the correct decision was ‘call duty doctor’.

Figure 1.

Survey used to assess confidence in decision-making when caring for a physically deteriorating patient

mhp.2020.e1519_0001.jpg

Additionally, before they undertook the NEWS workshop, participants were asked to rate their level of self-confidence in clinical decision-making concerning the two case studies using a Likert scale, from 1 to 5 with a score of 1 indicating the lowest level of confidence, and 5 indicating they were fully confident. Following the NEWS workshop, participants were asked to examine the same two case studies, but this time using the NEWS form to rate their level of confidence, again with a Likert scale.

Participants and setting

The setting of this study was an Irish mental health service, which includes a large hospital where the study took place. The service is a private organisation that operates outside of the Irish national HSE. There are approximately 250 nurses working at this service. The NEWS workshop was piloted with registered mental health nurses working in a ward focused on the care of older people with mental health issues. This ward was chosen as a pilot site because the patients there were most at risk of physical deterioration; the study therefore used a convenience method of sampling. To attract the largest possible number of participants, the NEWS workshop was provided to mental health nurses on-site in the hospital setting.

Educational workshop

The aim of the NEWS workshop was to increase the confidence of mental health nurses when working with physically deteriorating patients. The workshop introduced NEWS using a PowerPoint presentation and allowed time for questions on its implementation. This was followed by examples of practical application of NEWS demonstrated through case studies and group exercises.

Ethical considerations

Ethical approval was obtained for this research from the hospital ethics committee where the study took place and consent was gained from all participants in the study.

Results

In total, 22 nurses completed the pre-NEWS workshop survey, and 18 nurses completed the post-NEWS workshop survey. The NEWS workshop took place on a busy ward at the hospital and four nurses had to return to their duties before they could complete the post-NEWS workshop survey.

The participants had been qualified for a mean duration of 10.3 years (SD=9.3), ranging from 0.6 to 35 years. All participants had worked on the ward for an average of 4.1 years (SD=3.7), ranging from 0.6 to 16 years. Of the 14 participants to provide details on their educational qualifications, 79% (n=11) held an undergraduate degree and 21% (n=3) held a postgraduate diploma.

Case studies

Patient A and patient B

In terms of patient A, before the NEWS workshop, most participants (n=19; 86%) incorrectly answered that their clinical decision would be to ‘repeat observations every 30 minutes’, while three participants (14%) correctly answered that they would ‘continue as usual’.

These results were reversed following the NEWS workshop. Most participants (n=15; 83%) correctly reported that they would ‘continue as usual’ with patient A, while three (17%) incorrectly reported that they would ‘repeat observations every 30 minutes’. Table 1 shows the pre- and post-NEWS workshop data for patient A.

Table 1.

Pre- and post-National Early Warning Score (NEWS) workshop data for patient A

mhp.2020.e1519_0001_tb1.jpg

In terms of patient B, fewer changes in responses before and after the NEWS workshop were observed. Before the NEWS workshop most participants (n=20; 91%) correctly reported that their clinical decision would be to ‘call duty doctor’. After the NEWS workshop, 100% (n=18) of participants reported the same decision. Table 2 shows the pre- and post-NEWS workshop data for patient B.

Table 2.

Pre- and post-National Early Warning Score (NEWS) workshop data for patient B

mhp.2020.e1519_0002_tb1.jpg

Confidence level in the soundness of clinical judgement

Participants were asked to rate their confidence levels in their clinical judgement when deciding which action to take. Participants were surveyed for patients A and B before and after the NEWS workshop. In the pre-NEWS workshop survey, participants had a mean confidence rating of 3.70 (SD=0.93), which increased by 0.82 points to 4.52 (SD=0.59) in the post-NEWS workshop survey. These mean confidence scores are demonstrated in Figure 2.

Figure 2.

Mean confidence scores before and after the National Early Warning Score (NEWS) workshop

mhp.2020.e1519_0002.jpg

Of the 18 participants who completed the post-NEWS workshop survey, none reported lower self-rated confidence after the workshop, however, 50% (n=9) did report the same level of confidence before and after the NEWS workshop. A further nine participants (50%) reported higher levels of confidence in the soundness of their clinical judgement after the NEWS workshop.

Discussion

The aim of this study was to evaluate the self-reported confidence of mental health nurses in recognising physically deteriorating patients in an Irish mental health setting. Participants were asked to recognise a physically deteriorating patient and make a clinical decision according to the NEWS tool.

The results showed that even though there were some incorrect responses before the NEWS workshop, levels of confidence in managing physically deteriorating patients were high and improved after the NEWS workshop. These results were in contrast to other research that has found that nurses’ confidence in recognising physically deteriorating patients in mental health settings was limited due to discrepancies in their knowledge (McBain et al 2016), role ambiguities (Happell et al 2014) and complex medical presentations (Shefer et al 2014).

The results of the confidence scores in this study were found to be similar to a previous study by Shaddel et al (2014), where the mean level of nurses’ confidence in their clinical judgement before the introduction of NEWS was 3.73, rising to 4.63 after an educational module. The results of this study indicated that in an educational setting the mental health nurses did not lack confidence in making decisions about physically deteriorating patients.

Responding effectively in ‘real-life’ clinical practice, however, requires nurse educators to ensure that nursing students are confident in using the knowledge and skills they have acquired during their training (Yang et al 2015). Converting theory into practice was not an objective of this study and the question remains whether the confidence displayed by nurses in this simulated exercise would translate into practice. In the introduction of NEWS across the mental health service following completion of this study, educational support was offered to nurses to assist in assimilating NEWS into their daily practice

There is limited literature available on the use of NEWS in psychiatric inpatient units. Although this study had limitations, especially the modest sample size and analytic restrictions, the results reflect those of Shaddel et al (2014) and indicated that the use of NEWS in mental health services can increase mental health nurses’ confidence levels and their ability to recognise and manage physically deteriorating patients. The results demonstrate the capacity for improvement in monitoring and physical care provision among mental health nurses, thereby increasing patients’ safety and survival rates.

The effectiveness of NEWS in this study may have been influenced by the high number of registered nurses involved in the evaluation and the considerable level of clinical experience they possessed. According to McGaughey et al (2017), the use of the EWS provides an objective method of monitoring deterioration with reduced variation in decision-making, which assists in empowering nurses who are experienced clinicians. However, the EWS becomes less effective where there is a lower ratio of trained to untrained staff, or where observations are delegated to junior staff with less experience (McGaughey et al 2017). This is a concerning issue in mental health and acute services in the Republic of Ireland and elsewhere, where skill mix and staff recruitment have become challenging issues. However, confidence in recognising, managing and supporting those with physical health issues is becoming a prerequisite in mental health nursing through various service delivery plans (HSE 2017, 2020). These have been developed to improve the physical health outcomes of individuals with mental health issues.

There are continued calls from practitioners and mental health policymakers to ensure that physical and mental health issues are managed in a more integrated way (de Hert et al 2011, Finnerty 2019, Firth et al 2019). Firth et al (2019) called for the implementation of a physical health culture in mental health services, which should include regular screening.

While the introduction of NEWS in this study may only constitute one element of the overall solution, it provides a structured and systematic method for recognising deteriorating patients as well as assisting nurses to make clinical decisions. In addition, the use of NEWS represents the emergence of a physical health culture from which other approaches can be implemented. Increasing mental health nurses’ confidence in providing physical care requires the provision of education that supports them to practise their clinical skills using tools such as NEWS in simulated settings, and before these are introduced to clinical settings.

The physical health of patients with mental health issues has received increasing attention in Irish mental health policy and practice guidance (HSE 2017). It is important to evaluate the provision of related educational initiatives such as clinical skills training to develop the confidence, knowledge and skills of mental health nurses in this area.

Although there are limitations to this type of learning experience, it has been proven to enhance knowledge development and skill acquisition, which contribute to greater confidence (Ogilvie et al 2011). The expected long-term outcomes of implementing a tool such as NEWS is a reduction in unexpected deaths, increased engagement by nurses with the physical health of patients receiving inpatient mental health care and improved communication across services.

Limitations

Further analysis of the significance of the results regarding the participants’ confidence in their clinical judgement could not be undertaken due to the small size of the sample. The data generated did not meet the criteria for further testing for statistical significance. This is in part due to the high number of ‘ties’ involved (the number of participants who had the same self-reported confidence score before and after the NEWS workshop), which would have invalidated these results. Further research using a larger sample would be recommended to validate these results.

Conclusion

This is the first study to investigate the self-reported confidence of mental health nurses in recognising physically deteriorating patients in an Irish mental health setting. Following the implementation of a NEWS workshop, mental health nurses demonstrated enhanced confidence in clinical decision-making about physically deteriorating patients, albeit in an educational setting. Routine skills appraisal, training and supervision are vital in ensuring that this confidence is appropriately supported and translated into clinical practice.

Implications for practice

  • The evolving role of the mental health nurse needs to include knowledge and skills in recognising and responding to physical health changes in patients

  • Providing appropriate training for staff in using an accessible tool like the NEWS has the potential to result in improved recognition of physical deterioration and a reduction in serious incidents

  • Mental health nurses who participate in physical health educational modules will increase their confidence to respond to physical health challenges, leading to enhanced patient outcomes

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