Reflection

International Journal of Mental Health Nursing (2002) 11, 24–33

INTRODUCTION

In recent years an increased awareness of mental illness has been developing accompanied by a growing expecta- tion that people experiencing mental health problems receive the highest possible standard of care when requiring treatment within general health services (Sharrock & Happell 2000a). Despite this expectation, research evidence supports the view that general and

comprehensive nurses do not feel confident in providing care for patient population (Bailey 1998; Fleming & Szmukler 1992; Gillette et al. 1996).

The Psychiatric Consultation-Liaison Nurse’s (PCLN) role has developed at least in part in response to the need of nurses from the general health system for expertise, guidance and support in providing care to patients experiencing mental health problems. Although this role is significantly more defined and further developed overseas, particularly in the USA (Sharrock & Happell 2000b), a gradual growth in Australian literature in this area has occurred over the last two decades (Fanker 1995; Gillette & Bucknell 1996; Gillette et al. 1996; Keane 1989; Meredith & Weatherhead 1980; Sharrock 1989; Sharrock & Happell 2000a; Sharrock & Happell 2000b).

Evaluation of the impact and effectiveness of the PCLN role has received very little attention as evidenced by the paucity of evaluation literature both in Australia

FEATURE ARTICLE

The psychiatric consultation-liaison nurse: Thriving in a general hospital setting

Correspondence: Brenda Happell, Centre for Psychiatric Nursing Research and Practice, School of Postgraduate Nursing, University of Melbourne, Level 1, 723 Swanston Street, Carlton, Victoria 3010, Australia. Email: [email protected]

Julie Sharrock, RN, Psych. Cert., Crit. Care Cert., BEd, MHSc (Psych.Nurs).

Brenda Happell, RN, BA (Hons), Dip Ed, PhD. Accepted March 2001.

Julie Sharrock and Brenda Happell Centre for Psychiatric Nursing Research and Practice, The University of Melbourne, Carlton, Victoria, Australia

ABSTRACT: One outcome of mainstreaming of psychiatric services into the general health system is that nurses working in general hospitals now have increased contact with patients experiencing mental health problems. The literature suggests that general and comprehensive nurses do not believe they have the skills, confidence and knowledge to care adequately for patients in their care who have a mental health problems. The Psychiatric Consultation-Liaison Nurse (PCLN) can assist and educate general nurses in the care of patients with mental health problems who are receiving care in a medical/surgical setting. This study is based upon the findings of a Nurse Practitioner Pilot Study funded by the Department of Human Services (Victoria). In this paper the authors will present a brief overview of the role and model of practice of the PCLN, the means of referral, a profile of consultations and an overview of educational and policy development activity. The findings of the evaluation based on a combination of a Health Professional Satisfaction Survey and Focus Group Interviews will also be presented. The positive contribution of the PCLN to the confidence of nurses and how this might impact on patient outcomes will be highlighted. The value placed on the PCLN role by general hospital staff is evidence of psychiatric nursing not just surviving but thriving.

KEY WORDS: consultation, general hospital, liaison, mental health problems, nurse practitioner- mental health nursing.

and internationally. The results presented in the available literature suggest the role to be highly valued. A nurse satisfaction survey of the PCLN service within a general hospital was undertaken in Canada. The evaluation was based on 75 referrals over a 3-month period (Newton & Wilson 1990). The findings of Newton and Wilson’s study highlighted the importance of accessibility, availability and clinical expertise of the PCLN as important aspects of that service. Similar findings arose when Roberts (1998) under- took a qualitative study of nursing staff on an haematology ward in the UK. However, Roberts’ study was limited in that it was small (n = 3) and the group interview was con- ducted by the PCLN providing service to the participants. This may have impacted on the honesty and accuracy of responses.

Two studies from the USA attempted to demonstrate the cost-effectiveness of the PCLN role. A study was designed to ascertain the relationship between PCLN contact and the care of patients who required ‘sitters’ (lay people employed to provide constant observation of patients considered at risk) in a large general hospital (Talley et al. 1990). The hypothesis was that PCLN contact with staff would improve documentation of mental status of patients and reduce resource utilization and untoward incidents in relation to patients requiring ‘sitters’. This was not found to be the case. A limitation of Talley et al.’s study was that the subjects were considered too ‘heterogeneous’ and that there were many other variables than PCLN inter- vention affecting the use and discontinuation of ‘sitters’. In contrast, Mallory et al. (1993) demonstrated a signifi- cant decrease in the use of sitters for the majority of patients referred to the consultation-liaison (C-L) service and who received consultation by nursing and medical C-L staff.

A local Australian project evaluated the role of the Psychiatric Nurse Consultant within the emergency department (Gillette et al. 1996). The consultants in Gillette et al.’s study undertook a role and function similar to the PCLN. Improved access and decreased length of stay for patients experiencing mental health problems in the Emergency Department and improved patient satis- faction were significant findings. Emergency department staff reported increased confidence, knowledge and skills in the care of these patients and improvements in staff attitudes towards this group.

In light of the increase in PCLN positions in recent years, the paucity of research evaluating this role was of concern. As our healthcare system continues to be directed by the principles of economic rationalism, the survival of this type of position will substantially depend on the ability to demonstrate improved outcomes. Clearly the need for research to articulate and evaluate the role of the PCLN was identified.

Model of psychiatric consultation-liaison nursing The Austin and Repatriation Medical Centre (A&RMC) is an 830-bed tertiary teaching hospital in north-eastern metropolitan Melbourne, Victoria, Australia. The Austin and Repatriation campuses provide general and specialist medical–surgical inpatient, day and outpatient care. The Royal Talbot Rehabilitation Centre (RTRC) operates on a third site and offers specialist services for patients with a range of disabilities.

The PCLN formed part of the C-L psychiatry service that provides psychiatric and mental health care to patients of the non-psychiatric services of the A&RMC and RTRC. The PCLN provided psychiatric nursing consultation to nurses and other healthcare professionals working within non-psychiatric services with the aim of facilitating inte- grated and holistic care of patients with mental health problems.

The PCLN model developed at the A&RMC integrates Caplan’s (1970) model of mental health consultation with a liaison model of practice (Sharrock & Happell 2000b). Caplan (1970) describes two types of consultation, case and administrative consultation.

Case consultation

The focus of this type of consultation is a patient with a mental health problem. Assessment of the patient’s problems (either directly through interview of the patient or indirectly through the consultee) is undertaken. The consultee is provided with recommendations in the care of that patient. Education and support of the consultee plays an integral role in case consultation (Caplan 1970; Sharrock & Happell 2000b).

Administrative consultation

In this type of consultation, the consultee is an organiza- tion (such as a general hospital) that requests the expertise of the consultant in relation to an organizational issue. The request may also be in relation to the development or review of a particular program within the organization. The consultant is considered to have expertise that can assist in the development of the program (Caplan 1970; Sharrock & Happell 2000b).

Liaison

Liaison refers to the regular interaction and close associa- tion between the C-L psychiatry service and the non- psychiatric service, its staff and patients (Lipowski 1986). Through clinical meetings and discussions the C-L team has an opportunity to identify potential/existing patient problems, intervene and minimize the effects of the problem for the patient and staff. In addition, liaison activity has a strong focus on education of staff in the recognition, management and prevention of psychosocial

PSYCHIATRIC CONSULTATION-LIAISON NURSE 25

and psychiatric problems in their patients (Lipowski 1991). The PCLN was also a resource to individual staff members on issues affecting them. In these situations, immediate support was provided but the primary intervention was to link staff with mental health resources such as counselling, debriefing and other relevant services, both within and external to the Medical Centre.

METHODOLOGY

The opportunity to conduct an evaluation of the PCLN emerged when the project was selected as one of the 12 demonstration models for the Victorian Nurse Practitioner Project (VNPP). The VNPP was an initiative administered by the Health Workforce Section of the Department of Human Services, Victoria. The first phase of the project was to develop a framework and process necessary for the implementation of the nurse practitioner role into the Victorian health system.

The selection of the PCLN role as a demonstration model for this project presented a valuable opportunity to undertake an evaluation of the PCLN role. One of the lim- itations, however, was that the methodology for the evalu- ation was largely directed by the broader VNPP statewide evaluation. The evaluation framework needed to be suffi- ciently broad to cater for 12 very different roles, and could therefore not be designed specifically for the PCLN role.

In order to gain a greater understanding of the role of the nurse practitioner, data on all clinical activities were collected by the PCLN over a 19-week period. For case consultation activity, data collection included: referring unit, position of referring staff member, demographic details of patient (age, gender, postcode), presenting problem(s), psychiatric and medical diagnosis and inter- ventions provided. Where the activity was related to education or an administrative consultation, data collec- tion included: the topic, staff with whom the activity was conducted, description of activity and time commitment involved. The data were entered into SPSS and analysis primarily took the form of descriptive statistics of the services provided.

In order to protect the confidentially of the staff using the services and more importantly the patients for whom the referral was made, no identifying data was recorded in the SPSS file. Unit registration numbers were used by the PCLN in the initial phases of data collection to enable accurate statistics to be collected on number of visits per referral. These data were deleted prior to its entry into SPSS. The recording of data in this manner was a routine part of the PCLN’s practice. Staff and patients were not required to provide any information that would not normally be collected.

The degree of satisfaction with the role of the nurse

practitioner was ascertained through the Health Professionals Perception Survey designed by the VNPP. The Statewide Evaluation Team developed this instrument for the purposes of collecting data from all 12 demonstra- tion projects. The validity and reliability of the instrument was established by the Evaluation Team prior to its use by the individual project teams.

The survey was distributed to 260 staff who had used the services of the PCLN. Participants were asked to complete the survey and send it to the VNPP team in an addressed prepaid envelope in order to maximize the honesty of responses and ensure confidentiality for the participants. One hundred and seventeen completed surveys were returned representing a response rate of 45%.

The questionnaire comprised a total of 11 questions. Seven were closed questions in which the participant was, for example, asked to rate the contribution of the nurse practitioner to improving the continuity of care for patients from a choice of five options ranging from ‘not well at all’ to ‘very well’. There were four open-ended questions in which participants were asked to describe, for example, how the nurse practitioner role has contributed to better health outcomes.

The questionnaire sought a broad range of information including the participants’ perception of the service provided by the PCLN including the patient care provided, the accessibility of the PCLN, the contribution to con- tinuity of care for patients and the degree to which a previously unmet need had been met. In a series of open- ended questions participants were asked to describe if and how the PCLN has enhanced their professional role and/or the professional nursing role and contributed to better health outcomes for patients. Finally, participants were asked to describe any additional benefits or limitations to the position.

The questionnaire data were analysed by the Statewide Evaluation Team as part of the overall VNPP. After com- pletion of this analysis the Evaluation Team provided the researchers with the raw data in Microsoft Excel format to facilitate the current research. The data were coded into SPSS for analysis. Descriptive statistics were used to analyse the data. Qualitative data was analysed using content analysis. The resulting themes were coded and entered into SPSS.

In addition to the above data collection methods spec- ified by the statewide Evaluation Team, the researchers conducted a series of focus groups. The aim of these inter- views was to elicit more detailed information on the impact of the PCLN in increasing the confidence of nurses and other staff in providing care for patients experiencing mental health problems, and ultimately in improving the standard of care for the patients themselves.

To recruit participants into the focus groups, the PCLN

26 J. SHARROCK AND B. HAPPELL

distributed a letter of invitation to staff initiating referrals. Interested people were asked to contact the coinvestiga- tor (rather than the PCLN) to avoid any perception of coercion. Sixteen nurses and one social worker participated in one of three focus groups. One group was held on each of the three campuses of the Medical Centre to facilitate accessibility.

The focus groups were semistructured. They were facilitated by the coinvestigator and research fellow, both of whom have considerable expertise in mental health nursing and qualitative research methodologies. Participants were asked a series of open-ended questions to encourage discussion of these issues. The PCLN did not participate in the focus groups to ensure the information provided represented an honest appraisal of the role. The focus group interviews were audiotaped and transcribed verbatim. The two group facilitators then independently reviewed the transcripts in order to identify the main themes. On completion, the two facilitators met to discuss their findings. Minor differences in thematic analysis were discussed and consensus was reached.

FINDINGS

Activities of the Psychiatric Consultation-Liaison Nurse Requests to the PCLN were accepted from all disciplines of staff working in the Medical Centre from each campus. Referral criteria were that the patient was an inpatient or day-patient of a non-psychiatric service, was 18 years or over and had a mental health problem. The working definition of a mental health problem used by the PCLN was a clearly diagnosed psychiatric condition as defined in DSM-IV (American Psychiatric Association 1994) or a disturbance in mental and/or interpersonal functioning that were considered to be primarily psychological in origin and likely to benefit from psychiatric nursing intervention (Mayou & Sharpe 1991).

During the data collection period from September 1999 to January 2000, 90 requests for case consultation were

received by the PCLN. Nurses were the primary users of this service, with other referrals originating from the C-L team, ward medical staff, psychiatric services, the methadone service and allied health. Further information is presented in Table 1.

The majority of referrals were initiated from the medical units. Further information is presented in Table 2.

The problems or issues most frequently precipitating a referral were risk of self-harm and aggression or hostility. In some instances the psychiatric diagnosis itself pre- cipitated the referral, with the most common diagnoses being substance-related, mood and anxiety disorders. A request for assessment, a review, or to monitor a patient with a mental health problem was also a reason for initiating a referral. Further information is presented in Table 3.

Mood, substance related, psychotic, personality, anxiety and cognitive disorders were most commonly identified in the psychiatric history of patients referred to the PCLN. In examining the histories of patients, a number of behav- ioural issues were also apparent. Self-harm, aggression and issues related to compliance with treatment. Further information is presented in Table 4.

Interventions

Only 30% (n = 27) of the patients were seen directly by the PCLN. The intervention most frequently used by the PCLN was the provision of advice/guidance/recommendations to the staff of the primary treating team, accounting for 23% of the PCLN’s clinical time. Thirteen per cent of the PCLN’s time was spent in direct patient contact and 2% with the patient’s family. The vast majority (90.5%) of inter- ventions took 5–20 min with the provision of education sessions (50 min) and the development of a comprehen- sive care plan (25 min), the most time intensive activities. More detailed information regarding the interventions is contained in Table 5.

Health professional perception surveys Nurses constituted 83.2% (n = 94) of total responses. The level and position varied from Division 2 (enrolled) nurses

PSYCHIATRIC CONSULTATION-LIAISON NURSE 27

TABLE 1: Referring staff members by classification

Staff position No. Percentage

Nurse Unit Managers 23 26 Associate Nurse Unit Managers 26 29 Ward Nursing Staff 13 14 C-L Team 14 15 Ward Medical Staff 8 9 Psychiatric Services 4 4 Methadone Service 1 1 Ward Allied Health Staff 1 1 Total 90 100

TABLE 2: Units referring patients to the PCLN

Referring unit No. Percentage

Medical Units 43 48 Specialist Surgery Units 15 17 Rehabilitation 14 16 Gastroenterology 7 8 Cardiothoracic 5 6 Neurosciences 3 3 Cancer 2 2 Operating Suite 1 1 Total 90 100

to Nurse Unit Managers. Medical staff including medical and psychiatric consultants and medical and psychiatric registrars accounted for 9.7% (n = 11) of participants. The

remaining responses comprised allied health and one patient advocate.

The responses to the survey questions indicated a very

28 J. SHARROCK AND B. HAPPELL

TABLE 3: Presenting problems

Presenting problem No. Percentage

Self harm (actual or intended) 20 22 Aggression/hostility 13 14 Request for assessment/monitoring/review 12 13 Substance-related disorders 10 11 Mood disorders 8 9 Anxiety disorders 8 9 Compliance with treatment issues 8 9 General behavioural disturbances/bizarre symptoms 8 9 Demanding/attention seeking behaviour 8 9 Schizophrenia and other psychotic disorders 7 8 Delirium, dementia, amnestic and other cognitive disorders 6 7 Conflict/tension 6 7 Abnormal illness behaviour 5 6 Dependency 4 4 Paranoid/persecutory symptoms 4 4 Request for advice/assistance/link with resources 4 4 Manipulation 3 3 Abnormal eating behaviour 3 3 Eating disorders 3 3 Agitation 2 2 Absconding/wandering 2 2 Drug seeking 1 1 Loss 1 1 Disinhibited behaviour 1 1 Malingering 1 1

TABLE 4: Psychiatric problems underlying referral to PCLN

Psychiatric problem No. Percentage

Mood disorders 34 38 Substance-related disorders 23 26 Self harm (actual or intended) 18 20 Schizophrenia and other psychotic disorders 15 17 Personality disorders 15 17 Conflict/tension 14 16 Anxiety disorders 11 12 Aggression/hostility 11 12 Delirium, dementia, amnestic and other cognitive disorders 11 12 Compliance with treatment issues 10 11 Issues regarding status as involuntary patient (Mental Health Act) 5 6 Somatoform disorders 4 4 Adjustment difficulties 3 3 General behavioural disturbances/bizarre symptoms 3 3 Abnormal illness behaviour 3 3 Paranoid/persecutory symptoms 3 3 Eating disorders 2 2 Demanding/attention seeking behaviour 2 2 Disinhibited behaviour 1 1 Malingering 1 1 Dependency 1 1 Absconding/wandering 1 1 Request for assessment / monitoring / review 1 1

high level of satisfaction with the services provided by the PCLN. The vast majority of participants (over 90%) found the services of the PCLN to be timely, accessible, well documented and professional. Difficulties accessing the PCLN were attributed to her hours of work, heavy workload and operational problems with her pager.

All participants agreed that since its introduction 18 months previously the PCLN role had met a previously unmet need. More specifically the need was considered to be very well met by 75% of participants, with only one participant (0.9%), considering that the need had not been met very well. All but one participant considered the services of the PCLN to have assisted in the provision of continuity of care. Again, the majority indicated that this had been done very well.

The participants identified that the PCLN had assisted them in executing their professional role. Only one par- ticipant disagreed with this statement. In further explain- ing this question the most common responses were: the ability to carry out their work in a more effective manner; improved patient management, particularly with ‘difficult patients’; improved continuity of care; and enhanced coping skills. The provision of education and support, guidance, encouragement and debriefing were also fre- quently mentioned. Less common responses included increased understanding, confidence and insight, and the liaison role. The following quote illustrates how this role has assisted other healthcare professionals in providing patient care:

It has supported nurses in the management of complex psychiatric patients. She has filled the gap between general nurses/doctors and those staff who are trained in psy- chiatry. I cannot convey how valuable I think this position is for the nurses in my clinical area.

It was pleasing to note that medical staff acknowledged the skills and attributes of the PCLN:

[the PCLN] has a wealth of experience, advice and infor- mation and handouts to bring to the case. As rotating registrar I have little experience and the PCLN has much to teach me when consultants are not approachable.

There was widespread acknowledgement by partici- pants that the PCLN contributed to improved health outcomes for patients. Most frequently this was attributed to: the provision of a more extensive service, improved patient management and continuity; support; education; and liaison and follow up. The following example highlights the importance of the role:

Outcomes for clients in the community/organization become more achievable because the PCLN helps to break down barriers in caring for clients with mental health issues and helps to explore a more in-depth understanding of client problems and how to handle them.

Similarly:

Not only does the PCLN give better outcomes for our patients, [this role] assists the staff and provides support enabling the unit to function better and provide better care for those with specific needs. She has also given us

PSYCHIATRIC CONSULTATION-LIAISON NURSE 29

TABLE 5: PCLN Interventions

Intervention No. Percentage

Advice/guidance/recommendations/liaising with treating team members 432 32.7 Consult/link with C-L services 157 11.9 Other documentation related to consultation with patient 128 9.5 Monitoring of mental health needs of patient via staff 120 9.1 Supportive counselling of patient 98 7.4 Monitoring of mental health needs of patient directly 61 4.6 Psychiatric nursing assessment of patient via staff 46 3.5 Development of a plan of care 34 2.6 Link with psychiatric services 34 2.6 Informal education 32 2.4 Patient education 32 2.4 Psychiatric nursing assessment of patient 31 2.3 Link with other services 25 1.9 Supportive counselling of family/significant others 17 1.3 Clarification and monitoring of Mental Health Act requirements 17 1.3 Education sessions 17 1.3 Provision of written material 13 1.0 Monitoring 1:1 nursing 12 0.9 Further assessment/corroborative history from family/ significant others 11 0.8 Education of family/significant others 5 0.4 Monitoring of mental health needs via family/significant others 3 0.2 Total 1323 100.0

information relating to those needing psych [sic] specials on the wards which makes our discharge planning easier as we don’t always have to wait for decisions from psych [sic] registrar before implementing plans.

The PCLN was considered by participants to enhance the established professional nursing role (only four did not consider this to be the case). This was most commonly attributed to: patient management and the provision of holistic care and advice, and the education of staff. Less frequently responses included: the PCLN is a good role for nursing, maintenance and promotion of psychiatric nursing standards, and professional/personal gains such as increased confidence. The following quote demonstrates the importance of this role:

The NP [PCLN] at our hospital has provided inservice education to let us know what service she provides. She is always available and has a profile in our unit. Even if we have a different psych registrar we still have a familiar face we can relate to in psych matters. She also has made it clearer when we need to call on other resources, e.g. psych nurse specialists.

The nursing perspective was considered a vital aspect of the PCLN service:

Emotional/psychological needs are a very specialized field and we need as much input and education to fully care for our patients’ total care. Doctors do not give us the information we need. The PCLN sees it from a nursing perspective and helps us with this in mind.

Participants were asked to identify any further benefits or limitations of the PCLN role. The provision of staff support and education were most commonly considered as the major benefits of the PCLN service. Other benefits referred to crisis situations including staff crisis, coun- selling, debriefing and follow-up; providing a good back- up service for medical staff in responding to requests and referrals; and patient advocacy. The following quote illustrates the breadth of functions undertaken by the PCLN:

Heighten staff awareness of patients needs, i.e. psychiatric conditions, increases nurses’ confidence in managing or working with people with difficult behaviours. Has input into organizational wide strategies such as writing policies about use of drug, alcohol, writing guidelines for staff to manage challenging behaviours of patients.

The major limitation to the PCLN role related to hours of availability. Participants expressed some frustration that a more extensive service was not available, as the follow- ing quote demonstrates:

Limits-hours, not accessible, e.g. over night when most problems occur, although guidelines were beneficial sometimes this was not enough.

For one participant the service was sometimes not compatible with the realities of the working environment, as stated:

I don’t know her hours, availability or job description and find some of her talks idealistic and not compatible with the busy workday. To assist patients and staff, much more day to day communication would be needed, e.g. attend handover, or ward rounds, talk to each patient and each staff member after.

Focus groups The high level of satisfaction with the services of the PCLN reflected in the health professional perception surveys (HPPS) was further highlighted through the focus group interviews. Through analysis of the data collected the following four main themes were identified: (i) making contact; (ii) helping staff; (iii) processes used by the PCLN; and (iv) attributes.

The focus groups produced a large amount of data which were analysed thematically. The breadth of data precludes a detailed discussion of all four themes. For the purposes of this study, discussion will be restricted to the theme of helping staff.

The specific approaches used by the PCLN that the participants found particularly helpful in caring for patients experiencing mental health problems included: providing strategies for dealing with specific behaviours, providing knowledge and expertise, facilitating the development of the nurses own skills, enhancing self-awareness, increas- ing the level of understanding of patients with mental health problems, containing nurses’ anxiety and improv- ing the outcomes for patients.

The PCLN was particularly useful in providing specific approaches to facilitate patient care as the following example illustrates:

She comes in and gives us ideas on how to manage the patients [and] the way we interact with the patients … She does have a way of giving us a bit more of an idea on how to cope with the … behaviour pattern [of the patient] and how to manage it.

The value not just of mental health knowledge but of specifically nursing knowledge and experience in this position was acknowledged:

She’s very practical … You can ask other people advice and they’ll [the doctors] say ‘don’t sedate them – see you later – good night’ but they’re not going to be there for 10 hours … she actually gives you good advice as a nurse on the ward how to manage a patient.

The participants referred to their own lack of knowl- edge and skills in the area of mental health nursing. In light of this, the support offered by the PCLN was described as invaluable. One participant described the manner in which

30 J. SHARROCK AND B. HAPPELL

PSYCHIATRIC CONSULTATION-LIAISON NURSE 31

the support of the PCLN was able to meet a need not previously met:

Management kept telling us if you come across a situation that is beyond your competency or you’re not comfortable with, you tell the person in charge and when we used to do that we never got any support. Now if you can tell some- one like the PCLN that you really don’t know how to deal with this patient – it’s way out of your depth – you’ve got no psych background whatsoever – she doesn’t treat you like an idiot or a moron, she’ll treat you as some-one who doesn’t have that knowledge base … so she’ll answer it for you. She’s good.

Not only was the support and assistance provided by the PCLN perceived as a valuable intervention in its own right, it was also considered to assist the nurses to develop their own individual skills, as the following example from one of the participants highlights:

I was able to develop my skills even better to go up and speak to … the patient very openly and discuss how he was feeling and then even get his mum involved. So I devel- oped a very good relationship and then I’d feed it back to the psychosocial meeting on a Thursday.

The particular patient referred to here was suicidal at the time. The participant had previously felt uncomfort- able discussing suicidality with a patient. She believed it was as a direct result of the PCLN’s intervention that she had been able to broach the subject and ultimately to develop a therapeutic relationship with the patient.

In addition to assisting nurses to further develop their own skills in caring for patients with mental health problems, the role of the PCLN was believed to facilitate self-awareness particularly in relation to the impact of patients’ behaviour on individual emotions, as the follow- ing example illustrates:

It’s great to debrief … it was just great for her to explain to us why we were feeling that … and to be able to talk through it and let us all know that we’re only human … and help us with coping strategies.

This self-awareness was seen to be directly beneficial to increasing the nurses’ level of understanding towards patients experiencing mental health problems.

One participant described the sense of fear which had tended to be evoked when a patient with a psychiatric diagnosis was in the unit:

… to a lot of staff they’re [the mentally ill] scary, they’re threatening … they [nurses] are scared for their safety and somebody like [the PCLN] can really reassure you that if you treat this person this way you know it should be ok or this is what you need to be safe and … you can’t put a price on the difference it makes.

The following example demonstrates how a greater understanding of mental health issues has assisted in coping:

… she [PCLN] helps the staff to understand why the behaviour is there and I think with the understanding it becomes easier for staff not to accept patient’s behaviour, but to be able to manage it without feeling angry with the patient …

The PCLN therefore clearly had a significant role in the containment of anxiety for nurses when caring for patients experiencing mental health problems. Numerous res- ponses illustrate the impact of the PCLN in this regard:

She has been my saviour so many times.

Similarly:

As soon as she’s involved you think ‘It’s going to be all right’.

The ultimate benefit of the PCLN service was reflected in improved patient outcomes:

… it provides consistency … granted you might not get everybody on the same track but generally … if it’s written down in front on their history and that people if they see it written down and they know how they should it just makes it so much better. People manage it better, its better for the patient, better for the family, better for the staff and it keeps things under control …

Receiving information regarding specific patients prior to admission to the ward facilitated the efficiency of this process. This information enabled the staff to feel prepared with strategies for dealing with these patients from the outset:

… if she knows a patient is coming … to us for rehab from the acute, she knows the patient so well she’ll give you a thorough handover about that patient … to be aware of these other issues and this is how we’ve been dealing with it and so already you know that this patient is trying to do this or do that and you’ve got strategies in place to cope with it.

Through this process the anxiety of staff was allayed and a more positive view of the patient was facilitated.

DISCUSSION

The VNPP provided an excellent opportunity to address the paucity of literature in evaluating the contribution of the PCLN within the general hospital environment. This was achieved on two main levels: first, through the articu- lation of the role of the PCLN at the A&RMC, including the model of practice adopted in this setting and through the extensive recording of the clinical activity undertaken as part of this role. This information is particularly useful in providing a more detailed understanding of the func- tions performed by the PCLN and the types of clinical needs serviced through this role. Furthermore, it has been used as a basis from which a set of competencies specifi- cally designed for the PCLN has been developed.

Second, it has enabled a thorough evaluation of the PCLN role to be undertaken with the collection of both quantitative and qualitative data. The responses from participants in both the HPSS and the Focus Group Interviews clearly demonstrate the value of this role as perceived by the staff who used this service. Although the majority of data came from nurses, the responses from other health professionals reveal acknowledgement of the contribution that such a position can make to health care on a broader level.

This information will hopefully be used to strengthen the need for PCLN positions in all general hospitals throughout Australia and New Zealand. The contributions to mental health nursing, however, do not end here. Through articulating the specialist roles that mental health nurses are currently engaged in, the profession as a whole becomes strengthened. It lends weight to the view that the value of mental health nursing and its associated skills should not be restricted to conventional mental health service provision.

This is not to suggest that this project represents all that needs to be done. It is intended to be a springboard for further research examining the actual and potential role of the PCLN in relation to improved outcomes for patients experiencing mental health problems. Such research would strengthen the status of the PCLN as an integral part of the healthcare system, and broaden acknowledge- ment of the vital contribution mental health nursing can make to the overall health of our community.

Limitations of the study While the results of this evaluation are extremely pleasing, it is important to note the limitations. The study was undertaken in one clinical environment in metropolitan Melbourne. The extent to which these results are repre- sentative of PCLN positions throughout Australia and New Zealand is impossible to determine in the absence of larger numbers of studies of this nature. The return rate of 45% for the HPSS presents a further limitation.

An usual feature of the present study is that it is the evaluation of a role fulfilled by one person. It is therefore extremely difficult to clearly delineate between the performance of a role and the individual attributes of a person. It is clearly evident from these findings that the PCLN was highly regarded on the basis of her skills, knowl- edge and expertise in mental health nursing. For most participants this would be their first exposure to a PCLN, and in evaluating the role they are largely evaluating the person. The extent to which the attributes which were so highly regarded could be assumed to be characteristic of all mental health nurses employed within a PCLN role is difficult to determine.

CONCLUSION

The findings of the present study have made a valuable contribution to the paucity of literature evaluating the role of the PCLN. Despite the identified limitations of this study it is apparent that the role of the PCLN was highly regarded and valued by the participants in this study. The PCLN role clearly has a significant place in providing the best standard of care for patients experiencing mental health problems, and in supporting the general nurses who care for them.

The evaluation of the role of the PCLN has enabled a greater explication of the potential contribution of mental health nursing to the broader healthcare system. The evaluation and articulation of positions such as this will enhance the profile of mental health nursing within the nursing profession. Further research is required in order to determine how characteristic these results are of similar positions.

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