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A national survey of practice nurseinvolvement in mental health interventions
Richard Gray RN BSc(Hons)
Tutor, Section of Psychiatric Nursing, Institute of Psychiatry
Ann-Marie ParrResearch Worker, Section of Psychiatric Nursing, Institute of Psychiatry
Susan Plummer BA MSc RN RNT
Research Worker, Section of Psychiatric Nursing, Institute of Psychiatry
Tom Sandford BSc(Hons) RMN
Mental Health Advisor, Royal College of Nursing, London
Susan Ritter MA RGN RMN
Lecturer, Section of Psychiatric Nursing, Institute of Psychiatry
Rosie Mundt-Leach BSc(Hons) RN MSc
Research Worker, Section of Psychiatric Nursing,
Institute of Psychiatry
David Goldberg KB MA BM BCh DM MSc FRCP FRCPsych
Professor of Psychiatry, Department of Psychiatry, Institute of Psychiatry
and Kevin Gournay CBE MPhil PhD CPsychol AFBPsS RN FRCN
Professor of Psychiatric Nursing, Section of Psychiatric Nursing,
Institute of Psychiatry, London, England
Accepted for publication 10 February 1999
GRAY R.,GRAY R., PARRPARR A.-M.,A.-M., PLUMMERPLUMMER S.,S., SANDFORDSANDFORD T., RITTER S.,T., RITTER S., MUNDTMUNDT-LEACH R.,-LEACH R.,
GOLDBERG D.GOLDBERG D. && GOURNAYGOURNAY K. (1999)K. (1999) Journal of Advanced Nursing 30(4), 901±906
A national survey of practice nurse involvement in mental health interventions
Background: The move in the United Kingdom (UK) from institutional to
community care has led to an inevitable increase in the involvement of practice
nurses (PNs) in mental health care. Around 20 000 PNs are currently working
in the United Kingdom (UK). However, the extent and nature of PN involvement
in delivering mental health interventions has not been adequately explored.
Aim: This study aimed to quantify practice nurses' involvement in delivering
mental health interventions in primary care settings. Method: A questionnaire
was sent to a random sample of 1500 practice nurses registered with the Practice
Nurse Forum at the Royal College of Nursing. Sixty per cent of questionnaires
were returned; however, once non-eligible respondents were removed an
adjusted response rate of 54% was achieved. Results: Practice nurses play a
Correspondence: Richard Gray, Section of Psychiatric Nursing,
Institute of Psychiatry, De Crespigny Park, London SE5 8AF, England.
E-mail: [email protected]
Ó 1999 Blackwell Science Ltd 901
Journal of Advanced Nursing, 1999, 30(4), 901±906 Issues and innovations in nursing practice
signi®cant role in the assessment and treatment of mental health problems, most
frequently via the administration of depot antipsychotics and the screening for
depression. However, antipsychotic side-effects were infrequently monitored
and PNs' understanding of treatment issues in depression is poor. These
®ndings may be associated with the reported lack of mental health training that
PNs have received. Conclusions: The ®ndings of this study have important
implications for the training of practice nurses in mental health, speci®cally in
the areas of medication management and the detection of mental disorders.
Keywords: depression, education, mental health, practice nurses, psychosis
INTRODUCTION
Recent estimates suggest that 20% of primary care atten-
dees suffer from well-de®ned mental disorders, and that
this increases to approximately 40% if minor disorders are
included (Goldberg 1995). Although the Department of
Health (England) has recognized that nurses employed in
general practice (PNs) are spending a signi®cant amount of
time working with people with mental health problems
(Department of Health/Royal College of Nursing, DoH/RCN
1996) the examination of the exact role of the PN has been
largely ignored in recent large scale surveys (Atkin et al.
1993, Paxton et al. 1996). Few studies have speci®cally
examined PN involvement in mental health interventions
(Thomas & Corney 1993, Armstrong 1997).
Thomas & Corney (1993) surveyed 98 PNs working in
south-east England, achieving a response rate of 72%.
Results demonstrated that 89% of PNs regularly see
patients with mental health problems, 87% reported that
they felt inadequately trained and 91% wanted more
training in this ®eld. However, the type of mental health
interventions PNs were involved in delivering was not
examined.
Sutherby et al. (1992) in a survey of 101 primary care
nurses reported that they had frequent contact with
patients with mental health problems. Nearly half (44%)
of respondents indicated that a third or more of their
patients had mental illnesses, with PNs stating that
they were frequently expected to administer depot
antipsychotics despite feeling inadequately trained and
supervized in the task. In a census of 12 589 PNs by Atkin
et al. (1993) 43á4% reported that identifying the early
signs of anxiety and depression was part of their role.
A survey conducted by Armstrong (1997) focused
speci®cally on PNs involvement in the assessment and
treatment of depression. Of the 3000 PNs sampled from
the National Asthma Training Centre database, the major-
ity of the 1006 respondents felt that they did not have
enough knowledge about the diagnosis and treatment of
depression and did not feel con®dent working with these
patients. However, the low response rate (30%), poor
sampling techniques and speci®c focus on depression,
necessitates a large scale, representative study examining
PNs' involvement in a range of mental disorders.
Recent studies have demonstrated that PNs detect only
23% of cases of depression (Plummer et al. 1997). The
training of PNs in the detection and management of
depression is currently being evaluated in a large-scale
randomized controlled trial (Plummer et al. 1997). Pilot
data have indicated that with adequate training it may be
possible to improve PNs' ability to detect and treat
depressed patients (Mann et al. 1998).
Whilst there is clear evidence that PNs are involved in
delivering mental health interventions, the nature and
extent of their involvement is unclear. This study aimed to
bridge this gap by undertaking a national survey of PNs'
involvement in delivering mental health interventions.
THE STUDY
Method
Because no national database or register of PNs exists, the
sample for this survey was drawn from a membership
database of the Practice Nurse Forum at The Royal College
of Nursing (RCN). The Forum has approximately 15 000
members from across the United Kingdom (UK). Although
members of the Forum do not have to be PNs the vast
majority has, at some point, worked in that capacity.
Justi®cation for the use of this database was reported by
Atkin et al. (1993) in their census of PNs. They observed
that most PNs (no ®gure reported) were members of the
RCN. This suggests that the RCN database will provide a
representative sample that can be con®dently generalized.
To estimate the required sample size a power calculation
was performed using ARCUS. This programme has been
developed speci®cally to estimate sample sizes for
surveys. With a margin for error of �5% and a 95%
con®dence interval, based on the assumption that there are
20 000 PNs working in the UK and 5% administer depot
antipsychotics several times a week, a sample of 784 was
required for this study. To meet these power requirements,
and assuming a response rate of 60%, a sample of 1500 PNs
was randomly selected from the RCN database.
R. Gray et al.
902 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(4), 901±906
QuestionnaireA 42-item questionnaire was developed based on previous
research (Atkin et al. 1993, Thomas & Corney 199311 ,
Armstrong 1997) and consultation with a group of clinical
and academic experts (a practice nurse advisor, professors
of nursing and psychiatry, a consultant psychiatrist and a
general practitioner). Advice was also sought from the
Department of Health and the Royal College of Nursing.
The questionnaire was designed to be brief and easy to
complete. A covering letter explained the nature and
purpose of the study and two consent forms were sent
with the questionnaire. The questionnaire was divided
into ®ve areas: demographic information, PNs' caseload,
involvement with depressed patients, involvement with
psychotic patients, and current and future training
requirements.
Information about the composition of caseloads was
obtained by asking PNs to estimate the proportion of
patients seen in the last 4 weeks who were suffering from
either serious and enduring mental disorders, such as
schizophrenia or manic depression, or other mental health
problems, such as mild depression, anxiety or a phobia.
Statements about the treatment of depression were rated
on a ®ve-point scale ranging from agree to disagree. The
research group paid considerable attention to ensuring
that questions were neutral and not leading (a copy of the
questionnaire is available on request from the authors).
Questionnaires were sent on 1 September 1997. Follow-
up questionnaires and a reminder letter were sent 8 weeks
later if nurses had not responded. Respondents were
asked to sign and return a completed consent form with
the questionnaire. If written consent was not obtained
PNs' questionnaires were not included in the study.
Results
Response rates and non-response biasOf the 1500 questionnaires sent out 903 (60%) were
returned. Of these 175 were invalid Ð 159 because
respondents had either never or were not currently
working as practice nurses and 16 were returned unopened
packages Ð an overall response rate of 54%. Sixty-eight
PNs responded to the questionnaire but refused to partic-
ipate, leaving 640 valid questionnaires.
The 46% of PNs who did not respond may represent a
signi®cant non-response bias. However, given that 195
respondents were not currently, or had never worked as, a
practice nurse it is likely that these reasons apply to a
proportion of the non-responders which may reduce the
non-response bias.
DemographicsOf PNs who responded, 638 (99á7%) were female and two
(0á3%) were male. The majority of PNs classi®ed them-
selves as white (n � 622; 97%) with 18 (3%) respondents
from other ethnic groups. The mean age of PNs was
43 years (SSDD 8á16; range 26±64).
All PNs held a professional quali®cation as either a state
registered nurse (SRN; n � 398; 62%) or a registered
general nurse (RGN; n � 242; 38%). Respondents held
joint registration in the following specialist areas: regis-
tered midwives (n � 166; 26%), registered sick children's
nurses (n � 22; 3á5%) and registered mental nurses
(n � 18; 3%). One hundred and seventy-®ve respondents
(27%) had been educated to diploma level or higher.
The practice settingFifty-one per-cent of respondents worked for a
fund-holding general practitioner (GP), and 43% for a
non-fund-holding GP. Six per cent of practice nurses
worked in other settings including Ministry of Defence
and NHS/Community Trusts. PNs worked on average
24á5 hours per week and had worked within the practice
for a mean of seven years. Practices had a median number
of 7400 registered patients (SSDD 4386, range 45±32 000).
Sixty-four per cent of practices had attached CPNs, 56%
had attached counsellors, 18% attached clinical
psychologists and 4% had other attached mental health
professionals (alcohol/addictions, relate, family therapy).
Case-loadsThe estimated mean number of patients seen in the last 4
weeks by respondents was 309. Ten per cent of PNs'
caseloads were reported as having psychological or mental
health problems. Serious and enduring disorders such as
schizophrenia made up 1á5% of PNs' caseloads and an
estimated 2% of patients seen by PNs were taking
antipsychotic medication.
Practice nurses and depressionApproximately half of respondents reported that
depressed patients ask for information about the symptoms
of depression (48%) and about antidepressant medication
(51%). It was also indicated that 44% of PNs gave infor-
mation and advice to patients and their families regarding
the nature of depression, 44% about the use of antidepres-
sant medication and 56% about counselling in depression.
Seventy-®ve per cent of respondents saw counselling as
the best treatment approach for mildly depressed patients.
Thirty-three percent agreed with the statement that cogni-
tive behaviour therapy is bene®cial in the treatment of
depression. Forty-two per cent of PNs did not agree with
the statement that antidepressant medication was the best
method of treating severely depressed patients. Fifty-two
per cent of respondents stated that antidepressants were
not drugs of addiction.
The administration of antipsychotic medicationOn average 39% (n � 250) of PNs never administered
depot antipsychotics. However, the majority (61%,
Issues and innovations in nursing practice Practice nurse survey
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(4), 901±906 903
n � 390) reported administering depots at least once a
month. Of these, 216 (55%) reported monitoring patients
for side-effects. The side-effects most frequently moni-
tored by PNs giving depots were weight gain (n � 231,
59%), hypotension (n � 180, 46%) and abnormal invol-
untary movements (n � 178, 45%). The side-effects that
were most infrequently monitored were sexual dysfunc-
tion (n � 101, 26%), urinary problems (n � 123, 31%) and
blurred vision (n � 126, 32%).
Involvement in mental health interventionsThe mental health interventions that PNs were
most frequently involved in were administering depot
antipsychotics (n � 392, 61%), ensuring compliance with
antipsychotic medication (n � 212, 33%) and monitoring
the side-effects of medication (n � 189, 30%).
Contact with mental health professionalsRespondents reported that the mental health professionals
with whom they have most contact were CPNs (30% some
contact, 7% frequent contact) and counsellors (29% some
contact, 8% frequent contact). PNs reported that they had
very little contact with psychiatrists (96% no contact),
social workers (87% no contact) or psychologists (93% no
contact). Forty per cent of PNs reported having no contact
with mental health professionals.
PNs' involvement in the arrangements made under the
Care Programme Approach (CPA) was also explored. Less
than 1% of respondents reported that they were always
involved in arrangements made under the CPA. Nine per
cent reported that they were sometimes involved and 90%
stated that they were never involved in arrangements
made under the CPA.
Mental health trainingIt was found that 451 practice nurses (70%) had received
no mental health training in the last 5 years. Of the 30%
who had attended at least one course relating to mental
health, depression study days, counselling skills training,
and stress and anxiety management, were the most
common.
Respondents ranked 10 key areas for mental health
training (1 � most important, 10 � least important). These
results are reported in Table 1.
DISCUSSION
The demographic pro®le of the population (age, gender,
ethnicity) for this study is comparable to the national
census of 16 488 PNs (Atkin et al. 1993). These two
studies are also comparable in terms of number of hours
worked each week by PNs, length of time working in the
practice, and settings where respondents work. Although
the response rate for this study was lower than that
reported by Thomas & Corney (1993), the sample was
close to that estimated by the power calculation,
suggesting that the results can be generalized.
Despite the ®ndings of Goldberg (1995) who reported
that up to 40% of primary care attendees might be
suffering mental health problems, respondents in the
present study reported that they saw relatively few
mentally ill patients. This result may support the ®ndings
of Plummer et al. (1997) that mental health problems tend
to go unrecognized by PNs. Alternatively, this result may
be due to the fact that people with mental health problems
are not seen by PNs but are treated by other members of
the primary health care team, such as CPNs and counsel-
lors. However, the effect of having a counsellor attached to
the practice was to increase signi®cantly the number of
patients with mental health problems seen by PNs
(t(584) � )3á09, P � 0á002). Attached CPNs had no signi-
®cant effect on the number of patients with mental health
problems seen by PNs. Therefore, it can be concluded that
if either counsellors or CPNs are attached to a practice the
number of mentally ill patients seen by PNs will not be
reduced.
Intervention
Mean rank (1 most important,
10 least important)
95% con®dence
intervals
Signs and symptoms of mental disorder 2á32 2á2±2á5Anxiety management 2á97 2á7±3á1Supportive psychotherapy/counselling 4á01 3á8±4á2Pharmacology 4á55 4á3±4á8Suicide prevention and self-harm 4á66 4á3±4á8Relaxation therapy 4á71 4á5±4á9Administering depot antipsychotics 4á74 4á6±5á2Interventions to enhance compliance 4á83 4á5±4á9Crisis intervention skills 4á86 4á6±5á1Behaviour modi®cation and therapy 5á55 5á4±5á8
Table 1 Respondent ranking
of most important areas for
training in relation to mental
health
R. Gray et al.
904 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(4), 901±906
The results of this study suggest that PNs are
frequently asked, and give advice, about the treatment
of depression. However, a poor understanding of treat-
ment issues in depression was observed. A similar
®nding was reported by Armstrong (1997) who demon-
strated low levels of understanding about the diagnosis,
management and treatment of depression among PNs.
These ®ndings are predictable given that less than a third
of PNs have attended a mental health course in the last
5 years. However, given the high incidence of depression
in primary care settings, this study highlights an urgent
need for training in detection and management of
depression.
It was found that 61% of PNs administered depot
antipsychotics at least once a month. This con®rms and
quanti®es the ®ndings of Sutherby et al. (1992) that
practice nurses are frequently expected to give depots.
However, the present study also revealed that only 55% of
PNs who gave depots monitored patients for adverse
effects of antipsychotics.
Respondents ranked training in the signs and symptoms
of mental disorder as the priority for training in relation to
mental health. Given the likely under-recognition of
mental health problems among the patients seen by PNs,
training in the detection of mental disorders should
facilitate early intervention and treatment.
The mental health interventions that PNs are most
frequently involved in delivering are the administration of
depot antipsychotics, ensuring compliance and moni-
toring the side-effects of medication, even though PNs
report that generally, they have received little speci®c
training in these interventions. However, respondents
did not indicate that training in administering depot
antipsychotics or in the use of interventions to enhance
compliance was a priority. This may suggest that PNs do
not believe that helping patients to manage their
medication is part of their role.
Given the prevalence of mental health problems in
primary care it seems logical that PNs should be targeted
strategically for training for formal mental health roles.
Such training would be in accord with the strategy
proposed by Goldberg & Gournay (1997) which seeks to
improve mental health care delivery by strengthening
the role of the primary care team. This is of course not a
new idea; Shepherd et al. (1966) recognized this
32 years ago.
It is interesting to contrast PNs' reported priorities for
training with those identi®ed by GPs. In a study by
Kerwick et al. (1998) both groups reported that training in
supportive psychotherapy/counselling was a high priority
whilst assessing suicidal risk was a low priority. Both
groups stated that training in the prescribing and admin-
istration of psychotropic medication was a low priority.
However, there was disagreement on the need for crisis
intervention skills, with PNs giving it a low and GPs a
high priority.
CONCLUSION
This survey constitutes a comprehensive investigation
into the extent of PN involvement in mental health care. It
was found that practice nurses are frequently involved in
delivering mental health interventions such as the admin-
istration of depot antipsychotics and the detection and
management of depression. However, there is evidence
that many instances of mental disorder go unrecognized
by practice nurses. These ®ndings are not surprising given
that the majority of PNs have received little mental health
training. Providing PNs with the necessary supervision
and training in mental health presents a signi®cant
challenge. CPNs, who are the psychiatric professionals
that PNs have most contact with, could provide some
supervision. However, speci®c training initiatives will
still be necessary to equip PNs with the mental health
skills they need. Given the large number of PNs who
require training the delivery of this training will need to be
innovative, potential methods may include distance
learning, the use of multimedia technology, or a national
programme of skills workshops. However the training is
provided, what is clear from this study is that PNs are
involved in working with people with mental health
problems and need to learn more skills to treat those
individuals effectively.
Acknowledgements
This study was supported by a grant from Lilly Psychiatry.
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