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.

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.

What's needed to increase research capacity in rural primary health care

The aim of this study is to identify ways to build research capacity within primary health. A consultation was undertaken in late 2004 using a combination of a one-page survey and a guided meeting format, in a primary health setting in rural NSW. Most (81.3%) of the 134 individuals consulted were part of an Area Health Service, with 12.7% from non-government settings. Most (80.6%) were clinicians, with a third (31.5%) nurses, 8.3% in medicine, and the remainder from a range of allied health professions. Eleven organisations were represented. The main  outcome measures were identification of support needs, processes to enhance research engagement, and barriers and enablers to clinicians’ research  involvement. The results showed that popular delivery modes for research training and support were courses and “one-to- one” advice. Writing topics were generally more popular than others. Common barriers were time and technology issues. A key enabler was a discipline-specific focus. This is one of few rural Australian  consultations on research needs in primary health conducted with a diverse  range of clinicians at the clinician level. It will direct future research capacity  building efforts towards maximising face-to-face discipline specific options and  minimising technology use.

Nursing work and nursing knowledge : exploring the work of women's health nurses, patterns of power and praxis

The majority of women's health nurses in this study work in generalist community health centres. They have developed their praxis within the philosophy and policies of the broader women's health movement and primary health care principles in Australia. The fundamental assumption underlying this study is that women's health nurses possess a unique body of knowledge and clinical wisdom that has not been previously documented and explored. The epistemological base from which these nurses' operate offers important insights into the substantive issues that create and continually shape the practice world of nurses and their clients. Whether this represents a (re)construction of the dominant forms of health care service delivery for women is examined in this study. The study specifically aims at exploring the practice issues and experience of women's health service provision by women's health nurses in the context of the provision of cervical cancer screening services. In mapping this particular group of nurses practice, it sets out to examine the professional and theoretical issues in contemporary nursing and women's health care. In critically analysing the powerful discourses that shape and reshape nursing work, the study raises the concern that previous analyses of pursing work tend to universalise the structural and social subordination of nurses and nursing knowledge. This universalism is most often based on examples of midwifery and nursing work in hospital settings, and subsequently, because of these conceptualisations, all of nursing is too often deemed as a dependent occupation, with little agency, and is analysed as always in relation to medicine, to hospitals, to other knowledge forms. Denoting certain discourses as dominant proposes a relationship of power and knowledge and the thesis argues that all work relations and practices in health are structured by certain power/knowledge relations. This analysis reveals that there IX are many competing and complimentary power/knowledge relations that structure nursing, but that nursing, and in particular women's health nurses, also challenge the power/knowledge relations around them. Through examining theories of power and knowledge the analysis, argues that theoretical eclecticism is necessary to address the complex and varied nature of nursing work. In particular it identifies that postmodern and radical feminist theorising provide the most appropriate framework to further analyse and interpret the work of women's health nurses. Fundamental to the position argued in this thesis is a feminist perspective. This position creates important theoretical and methodological links throughout the whole study. Feminist methodology was employed to guide the design, the collection and the analysis. Intrinsic to this process was the use of the 'voices' of women's health nurses as the basis for theorising. The 'voices' of these nurses are highlighted in the chapters as italicised bold script. A constant companion along the way in examining women's health nurses' work, was the reflexivity with feminist research processes, the theoretical discussions and their 'voices'. Capturing and analysing descriptive accounts of nursing praxis is seen in this thesis as providing a way to theorise about nursing work. This methodology is able to demonstrate the knowledge forms embedded in clinical nursing praxis. Three conceptual threads emerge throughout the discussions: one focuses on nursing praxis as a distinct process, with its own distinct epistemological base rather than in relation to 'other' knowledge forms; another describes the medical restriction and opposition as experienced by this group of nurses, but also of their resistance to medical opposition. The third theme apparent from the interviews, and which was conceptualised as beyond resistance, was the description of the alternative discourses evident in nursing work, and this focused on notions of being a professional and on autonomous nursing praxis. This study concludes that rather than accepting the totalising discourses about nursing there are examples within nursing of resistance—both ideologically and X in practice—to these dominant discourses. Women's health nurses represent an important model of women's health service delivery, an analysis of which can contribute to critically reflecting on the 'paradigm of oppression' cited in nursing and about nursing more generally. Reflecting on women's health service delivery also has relevance in today's policy environment, where structural shifts in Commonwealth/State funding arrangements in community based care, may undermine women's health programs. In summary this study identifies three important propositions for nursing: • nursing praxis can reconstruct traditional models of health care; • nursing praxis is powerful and able to 'resist' dominant discourses; and • nursing praxis can be transformative. Joining feminist perspectives and alternative analyses of power provides a pluralistic and emancipatory politics for viewing, describing and analysing 'other' nursing work. At the micro sites of power and knowledge relations—in the everyday practice worlds of nurses, of negotiation and renegotiation, of work on the margins and at the centre—women's health nurses' praxis operates as a positive, productive and reconstructive force in health care.

Healthy markets - healthy people/ : reforming health care in Cambodia

Health care reform has been described as a global epidemic. This thesis deals with nature and experience of health care reform in developing countries. Increasing privatisation, economic transition, and structural adjustment have provided the context for health system changes. Different approaches to reform have been developed by international organisations such as the World Bank, WHO and UNICEF. What has driven national health care reforms? Are such policies really appropriate to developing countries? Has a consensus now emerged in relation to international health policy? Has a new health care ‘model’ appeared? The study of health care reform in Cambodia is a timely opportunity to investigate the implementation of health care reform under extreme conditions. These conditions include a legacy of genocide, long-term conflict, political isolation, and economic transition. This case study uses both qualitative and quantitative methods and multiple sources of data to analyse the reform program. The study reinforces the conclusion that, under conditions of extreme poverty, market based reforms are likely to have limited positive impact. Rather, understanding the cultural conditions that determine demand, delivering health care of a satisfactory quality, providing appropriate incentives for health practitioners, and supporting services with adequate public funding are the prerequisites for improved service delivery and utilisation. Cambodia's strategy of integrated district health service development and universal population coverage may provide an instructive example of reform. Emerging policy issues identified by this case study include the fundamental role of equity in service provision, the influence of the social determinants of health and illness and interest in the appropriate use of evidence in international health policy-making.

Train the trainer model : implications for health professionals and farm family health in Australia

Australia is a large country with 60% of land used for agricultural production. Its interior is sparsely populated, with higher morbidity and mortality recorded in rural areas, particularly farmers, farm families, and agricultural workers. Rural health professionals in addressing health education gaps of farming groups have reported using behavioralist approaches. These approaches in isolation have been criticized as disempowering for participants who are identified as passive learners or 'empty vessels.' A major challenge in rural health practice is to develop more inclusive and innovative models in building improved health outcomes. The Sustainable Farm Families Train the Trainer (SFFTTT) model is a 5-day program developed by Western District Health Service designed to enhance practice among health professionals working with farm families in Australia. This innovative model of addressing farmer health asks health professionals to understand the context of the farm family and encourages them to value the experience and existing knowledge of the farmer, the family and the farm business. The SFFTTT program has engaged with health agencies, community, government, and industry groups across Australia and over 120 rural nurses have been trained since 2005. These trainers have successfully delivered programs to 1000 farm families, with high participant completion, positive evaluation, and improved health indicators. Rural professionals report changes in how they approach health education, clinical practice, and promotion with farm families and agricultural industries. This paper highlights the success of SFFTTT as an effective tool in enhancing primary health practice in rural and remote settings. The program is benefiting not only drought ravaged farmers but assisting rural nurses, health agencies, and health boards to engage with farm families at a level not identified previously. Furthermore, nurses and health professionals are now embracing a more 'farmer-centered model of care.'

The quality and outcomes framework reduces disparities in health outcomes for cardiovascular disease

Jamie Robinson, the Berkeley health economist, famously remarked in 2001 that ‘the three worst ways to pay doctors are salary, capitation and fee-for-service.’ Different financial incentives produce different clinical and service outcomes, sometimes perversely.1 In 2004, the UK government introduced pay for performance (P4P) for general practitioners, the Quality and Outcomes Framework (QOF). Its introduction was associated with the general trend in the National Health Service away from placing implicit trust in doctors and more active monitoring of their performance. One-quarter of GP pay can be earned from achieving scores on 147 indicators.2 These indicators were acceptable to doctors because the majority are evidence-based clinical outcome measures for 10 chronic diseases. Others relate to patient access and satisfaction, and practice organisation.

Description and qualitative evaluation of Jigsaw, an integrated young persons' mental health program

Objective: The aim of this paper is to describe the establishment of an integrated young person’s mental health service and the findings of a qualitative evaluation conducted 2 years after its establishment.
Method: A qualitative evaluation of the service was undertaken using a semi-structured interview, a service satisfaction survey and partnership analysis tool.
Results: The major problems encountered in establishing the service were insufficient recognition of the cultural challenges in working together, difficulty in recruiting general practitioners, establishing a youth friendly environment and maintaining the quality of the relationship between partners.
Conclusion: Despite almost 3 years of preparation, many important aspects of change management were underestimated or inadequately attended to.

A descriptive interview with 64 patients discharged from an acute-psyciatric-inpatient service

Background Acute-mental-health services receive hundreds of admissions every year. Some of these patients will continue to be case-managed by community mental-health teams on discharge from the acute unit while others will not remain in contact with the mental-health service. This study compares the findings of comprehensive interviews conducted with current and past patients of the community mental-health service 3 or more years following case closure from the community ambulatory service.
Methods Between 1 July 1999 and 30 June 2001, there were 2245 closed cases identified at Barwon Health. Letters of invitation to participate in a research project were sent to people who had suffered from psychotic illnesses, and had been case-closed by community mental-health services between the above dates and had not been in contact with the Community and Mental Health Service for at least 6 months. A second group of participants was recruited from people who had also been case-closed by community mental health teams in Barwon Health during the 1999–2001 2-year-time window but whose cases had been re-opened and who were in case management with Barwon Health at the time of the study. All participants were interviewed using the Diagnostic Interview for Psychosis.
Results Letter responses were received from 17 men and 18 women, aged 40.7 ± 12.0 (mean ± SD), who were interviewed. A second group of 17 men and 12 women, aged 40.9 ± 9.6 (mean ± SD) of currently case-managed patients was interviewed. All interviewees reported a detailed history of mental illness. Persistent social dysfunction and impaired quality of life were reported in both groups.
Conclusion Patients suffering from psychotic disorders who had been case-closed by community mental-health teams and had been discharged to the care of their general practitioners or elsewhere continued to show evidence of significant impairment due to mental illness 3 years after being case-closed.

Dialysis residential care : a future dialysis service model

People with chronic kidney disease are ageing and have increasing co-morbidities. The current delivery of renal replacement therapy, dialysis and transplantation, needs to adjust to changing patient needs. This paper proposes a potential future service delivery model featuring a dialysis residential care facility and a care coordination focus. The residential care facility would be composed of four levels of care; high, hostel, independent and outpatient. The paper argues that this model may result in decreased morbidity, improved patient quality of life and may prove cost effective. Patients' nutritional status, medication adherence and transport efficiency may be improved. We propose this model to stimulate further debate in order to meet the needs of current and future chronic kidney disease patients.

Mental health, criminal justice and culture : some ways forward?

Objective: This paper aims to offer an overview of the mental health needs of Indigenous men and women in the criminal justice system and how Indigenous cultural perspectives on mental health might infl uence forensic mental health service provision.
Conclusion: There is a need for both mental health and criminal justice agencies to collaborate more closely in developing new models of service provision that incorporate Indigenous perspectives on social and emotional wellbeing, recognize culturally specifi c mental health risk and protective factors in relation to prevention, early intervention and treatment, and take advantage of the opportunities for treatment that arise in the context of criminal justice system intervention.

Use of the program explication method to explore the benefits of a service for homeless and marginalized young people

Maintaining the alignment between the dynamic development of health and social services and the rapidly advancing scientific evaluation literature is a central challenge facing service administrators. We describe “program explication,” a consulting method designed to assist services to identify and review implicit program logic assumptions against the evaluation literature. Program explication initially facilitates agency staff to identify and document service components and activities considered critical for improving client outcomes. Program assumptions regarding the relationship between service activities and client outcomes are then examined against available scientific evidence. We demonstrate the application of this method using an example of its use in reviewing a service for homeless young people operating in Melbourne, Australia, known as the Young People's Health Service (YPHS). The YPHS involved 21 activities organized within 4 components. The intended benefits of each of the activities were coherently articulated and logically consistent. Our literature search revealed moderate to strong evidence for around 1 quarter of the activities. The program explication method proved feasible for describing and appraising the YPHS service assumptions, thereby enhancing service evaluability.

Tackling health inequalities : what do senior managers think

Objective: To describe how New South Wales (NSW) Area Health Service Chief Executive Officers (CEOs) understood concepts of equity in the development of NSW Health's Equity Statement; CEO knowledge and interpretation of a given concept being one aspect of developing policy.

Design and Setting: This paper describes the process through which NSW Area Health Service CEOs were involved in developing the Equity Statement, specifically:

1. Briefings with individual CEOs on key issues and identification of possible difficulties and potential 'equity champions'.
2. A two-hour workshop to explore ('pre-mortem') why the proposed statement might fail.
3. CEO involvement in identifying strategies that promoted equity already operating locally.
4. C onsultations with selected individuals about the draft recommendations.
5. Feedback to CEOs.

The article provides a case study of consultative policy making by illustrating how participant knowledge can both inform and be strengthened by involvement in the policy development process.

Results: There was a high level of awareness among CEOs of health inequalities and an acceptance of their responsibility to address them. They saw three main ways of doing this: a) equity of resource allocation for health service delivery within and between regions; b) equity of access to health services based on need; and c) equity of health outcomes. CEOs felt that making the health system accountable for health outcomes would provide pressure for system-wide resource allocation changes. They recognised that factors substantially impacting on health outcomes were outside the control of the health system. Furthermore, finding a balance to which they could be held accountable was difficult. All CEOs saw ensuring needs-based access to services as a key area where they could potentially have an impact; and they specifically saw challenges in a conflict between equity and efficiency, marginalisation of special treatment for disadvantaged people, balancing investment in rescue services and prevention/early intervention, and developing a rational health financing system. The resulting policy has been broadly embedded within the NSW health system with strong local support.

Conclusion: The NSW Health and Equity policy was embedded because CEO leadership and acceptance of the policy enhanced local ownership.