Mental health triage nursing : an Australian perspective

This paper presents the findings of a doctoral research project that involved a state-wide investigation into mental health triage nursing in Victoria, Australia. Mental health triage is a specialized domain of nursing practice that has emerged within the context of wider mental health reform in the State. The overall aim of the study was to produce a comprehensive definition and description of psychiatric triage nursing in Victoria. Methodological triangulation was used in the design of the study to enable the use of both survey (n = 139) and semi-structured interview (n = 21) data collection methods. Mental health triage nursing was found to be a complex, stressful role that involves high levels of responsibility, clinical decision making, and multiple role functions, many of which overlap into areas of practice previously the exclusive domain of medicine, such as assessment, diagnosis, and referral. The paper raises discussion on contemporary professional issues of concern to mental health triage nursing, and concludes with recommendations for the future development of the discipline.

Mental health triage : towards a model for nursing practice

Mental health triage/duty services play a pivotal role in the current framework for mental health service delivery in Victoria and other states of Australia. Australia is not alone in its increasing reliance on mental health triage as a model of psychiatric service provision; at a global level, there appears to be an emerging trend to utilize mental health triage services staffed by nurses as a cost-effective means of providing mental health care to large populations. At present, nurses comprise the greater proportion of the mental health triage workforce in Victoria and, as such, are performing the majority of point-of-entry mental health assessment across the state. Although mental health triage/duty services have been operational for nearly a decade in some regional healthcare sectors of Victoria, there is little local or international research on the topic, and therefore a paucity of established theory to inform and guide mental health triage practice and professional development. The discussion in this paper draws on the findings and recommendations of PhD research into mental health triage nursing in Victoria, to raise discussion on the need to develop theoretical models to inform and guide nursing practice. The paper concludes by presenting a provisional model for mental health triage nursing practice.

Round the bend : a brief history of mental health nursing in Victoria, Australia 1848 to 1950's

This paper presents a history of mental health nursing in Victoria, Australia from 1848 to the 1950's, or the asylum years to the era of the mental hospital. The research for this historical overview was conducted as part of a literature review for a mental health nursing doctoral thesis, which included an account of the evolution of the profession from asylum attendant to the present time. The literature reviewed for this project revealed a distinct lack of a coherent, chronological account of the historical development of mental health nursing in Victoria, and this paper seeks to address that knowledge gap.

An exploration of clinical decision-making in mental health triage

Mental health (MH) triage is a specialist area of clinical nursing practice that involves complex decision making. The discussion in this article draws on the findings of a Ph.D. study that involved a statewide investigation of the scope of MH triage nursing practice in Victoria, Australia. Although the original Ph.D. study investigated a number of core practices in MH triage, the focus of the discussion in this article is specifically on the findings related to clinical decision making in MH triage, which have not previously been published. The study employed an exploratory descriptive research design that used mixed data collection methods including a survey questionnaire (n = 139) and semistructured interviews (n = 21). The study findings related to decision making revealed a lack of empirically tested evidence-based decision-making frameworks currently in use to support MH triage nursing practice. MH triage clinicians in Australia rely heavily on clinical experience to underpin decision making and have little of knowledge of theoretical models for practice, such as methodologies for rating urgency. A key recommendation arising from the study is the need to develop evidence-based decision-making frameworks such as clinical guidelines to inform and support MH triage clinical decision making.

Developing Clinical Practice Guidelines for violence risk assessment in mental health triage : a systematic review

Background : On a global level, there is a growing trend to utilise mental health triage service systems as a way of providing consumers with access to 24 hour mental health care. At present, violence risk assessment in mental health triage lacks a suitable evidence base and clear guidelines. This presentation provides an overview of a Clinical Practice Guideline for violence risk assessment at point of entry to health services.
Aims : The objective of this study was to develop Clinical Practice Guidelines for violence risk assessment in mental health triage, and to pilot test the Clinical Guidelines in two major hospitals in Melbourne.
Method : The method employed in the study was a systematic review, as per the Australian National Health and Medical Research Council’s methodology for developing Clinical Guidelines. Research was conducted at the Royal Melbourne Hospital and the Alfred Hospital to establish the utility of the Guideline in practice.
Results : The systematic review established the highest level of evidence for violence risk assessment. Clinical Practice Guidelines for mental health triage were developed from these findings.
Conclusions : Evidence based Clinical Guidelines maximise the potential for creating safer outcomes for consumers, families/carers, and health care workers.

Practice into theory : working collaboratively with clinicians to articulate mental health triage practice

Learning objectives: To contribute to mental health nurses understanding and knowledge of mental health triage practice through the presentation of current research findings on the topic. A specific focus of the paper will be an overview of how mental health triage practice differs across the lifespan.

Mental health triage is a highly specialised area of clinical practice for mental health nursing that is in its infancy in terms of articulating practice and theory. This paper addresses the conference theme of mental health nursing practice: new roles, new challenges by presenting the findings of a qualitative research project that investigated mental health triage/duty/intake practices across the five community mental health agencies of The Alfred Hospital, Melbourne. The overall aim of the project was to work collaboratively with clinicians to further develop the quality and consistency of mental health triage, duty, and intake clinical practice across all arms of Alfred Psychiatry. The project was designed to facilitate the expansion of the mental health triage knowledge base, and thus contribute to the further development of triage clinical practice. One of the unique aspects of the project was its triangulation across the adult triage service (acute), the two Continuing Care Teams, and the specialist psychiatric services such as the Child and Adolescent Mental Health Service, the Homeless and Outreach Psychiatric Service, and the Mobile Aged Psychiatric Service. The project employed focus group method to collect in-depth, qualitative data. A series of nine focus groups were conducted at each site, which concentrated on eliciting data on the core areas of mental health triage practice such as telephone consultation skills, mental status examination, risk assessment, decision-making, negotiation, crisis assessment, secondary consultation, and documentation. The investigation produced a considerable amount of high quality, in-depth data that was analysed using content analysis methods. The project produced data that will make a significant contribution to the expanding body of knowledge on mental health triage practice.

Decisions, decisions, decisions : an exploration of clinical decision-making in mental health triage

This paper presents the findings of a project that investigated mental health triage/duty/intake practices across the five community mental health agencies of The Alfred Hospital, Melbourne. The overall aim of the project was to work collaboratively with clinicians to further develop the quality and consistency of mental health triage, duty, and intake clinical practice. The project was designed to facilitate the expansion of the mental health triage knowledge base, and thus contribute to the further development of triage clinical practice. One of the unique aspects of the project was its triangulation across the adult triage service (acute), the two Continuing Care Teams, and the specialist psychiatric services such as the Child and Adolescent Mental Health Service, the Homeless and Outreach Psychiatric Service, and the Mobile Aged Psychiatric Service. The project employed focus group method to collect in-depth, qualitative data. A series of nine focus groups were conducted at each site, which concentrated on eliciting data on the core areas of mental health triage practice such as telephone consultation skills, mental status examination, risk assessment, decision-making, negotiation, crisis assessment, secondary consultation, and documentation. The investigation produced a considerable amount of high quality, in-depth data that was analysed using content analysis methods. The focus of this paper is on presenting the data on clinical decision-making that was raised through the project.

How deinstitutionalisation and the current public mental health system affects individuals with schizophrenia : four case reports

The professional component of this thesis focuses on how deinstitutionalisation and the current public mental health system have affected individuals with schizophrenia. Chapter one discusses the process of deinstitutionalisation and the research that has examined the impact of this initiative. Chapter two concentrates on schizophrenia, specifically the symptoms, course, etiological theories and treatments of this illness. Four case studies are then provided in order to explore how deinstitutionalisation and the current mental health system have affected individuals with schizophrenia. The names and identifying characteristics of these clients and their families have been modified to ensure anonymity. Chapter three describes a 47 year old woman, AA, who was referred for a neuro-psychological assessment. Chapter four outlines the second case study, a 23 year old male, BB, who was referred for a psychological assessment regarding diagnosis and treatment recommendations. Chapter five describes the third case study, a 54 year old woman, CC, who was referred for therapy and consultation regarding future treatment recommendations. Chapter six discusses the fourth case study, a 21 year old male, DD, who was seen for crisis intervention and treated in the community. Each of these case studies outlines the background history, formulation and treatment approaches. These case reports are used to illustrate how deinstitutionalisation and the present public mental health system affect individuals with schizophrenia. Chapter seven provides an overall discussion and conclusion to these case studies.

Assessing cost-effectiveness in mental health: helping policy-makers prioritize and plan health services

Objective: We assessed, from a health sector perspective, options for change that could improve the efficiency of Australia's current mental health services by directing available resources toward 'best practice' cost-effective services.

Method: We summarize cost-effectiveness results of a range of interventions for depression, schizophrenia, attention deficit hyperactivity disorder and anxiety disorders that have been presented in previous papers in this journal. Recommendations for change are formulated after taking into account 'second-filter criteria' of equity, feasibility of implementing change, acceptability to stakeholders and the strength of the evidence. In addition, we estimate the impact on total expenditure if the recommended mental health interventions for depression and schizophrenia are to be implemented in Australia.

Results: There are cost-effective treatment options for mental disorders that are currently underutilized (e.g. cognitive–behavioural therapy (CBT) for depression and anxiety, bibliotherapy for depression, family interventions for schizophrenia and clozapine for the worst course of schizophrenia). There are also less cost-effective treatments in current practice (e.g. widespread use of olanzapine and risperidone in the treatment of established schizophrenia and, within those atypicals, a preference for olanzapine over risperidone). Feasibility of funding mechanisms and training of staff are the main second-filter issues for CBT and family interventions. Acceptability to various stakeholders is the main barrier to implementation of more cost-effective drug treatment regimens. More efficient drug intervention options identified for schizophrenia would cost A$68 million less than current practice. These savings would more than cover the estimated A$36M annual cost of delivering family interventions to the 51% of people with schizophrenia whom we estimated to be eligible and this would lead to an estimated 12% improvement in their health status. Implementing recommended strategies for depression would cost A$121M annually for the 24% of people with depression who seek care currently, but do not receive an evidence-based treatment.

Conclusions: Despite considerable methodological problems, a range of cost-effective and less cost-effective interventions for major mental disorders can be discerned. The biggest hurdle to implementation of more efficient mental health services is that this change would require reallocation of funds between interventions, between disorders and between service providers with different funding mechanisms.