Mental health nurses working in primary care: Perceptions of general practitioners

Feature Article

Mental health nurses working in primary care:Perceptions of general practitioners

Tom Meehan1 and Samantha Robertson2

1The Park, Centre for Mental Health and University of Queensland, and 2The Park, Centre for Mental Health andQueensland University of Technology, Richlands, Queensland, Australia

ABSTRACT: The Mental Health Nurse Incentive Program (MHNIP) was established across Aus-tralia during 2007. Under the guidelines for the program, mental health nurses work in partnershipwith general practitioners (GPs) to assist in the assessment and treatment of those with more severemental health problems. This paper provides insights, from the perspective of GPs, on the qualitiesrequired of mental health nurses seeking employment in the primary care setting. A descriptive,exploratory approach was employed to isolate relevant themes. Discussion groups were conductedwith 25 GPs involved with the Mental Health Nurse Incentive Program. These discussion groups wereaudio-taped, transcribed, and analyzed using content analysis. Five overarching thematic clustersemerged from the data: (i) ‘fitting in’; (ii) knowledge; (iii) skills; (iv) supporting GPs; and (v) educatingGPs. While GPs recognize the valuable contribution that mental health nurses can make in thetreatment of those with mental health problems, this appears to be dependant on the knowledge andskills of the nurses involved and their ability to engage with GPs. Ongoing education and otherpractical interventions are required to ensure that GPs are better informed about the initiative.

KEY WORDS: general practitioners, mental health nurses, Mental Health Nurse Incentive Program,perceptions.

INTRODUCTION

The Mental Health Nurse Incentive Program (MHNIP)was introduced across Australia during 2007 to improveaccess to treatment for those with severe mental healthproblems (Council of Australian Governments 2006). TheMHNIP provides funding to general practitioners (GPs),psychiatrists, and divisions of general practice to employmental health nurses to assist in the treatment and coordi-nation of services for those with more severe mental healthproblems. To be eligible for support, the person shouldhave a diagnosis of mental disorder, and the disordershould cause significant disablement in functioning so that

it places the patient at risk of hospitalization (AustralianGovernment, Department of Health & Ageing 2010).

Under the guidelines established for the MHNIP,mental health nurses are expected to work closely withGPs to provide a suite of interventions aimed at enhanc-ing patient outcomes. These interventions are likely toinclude the planning of patient care, providing periodicreviews of the patient’s mental state, monitoring medica-tion, linking patients to other health professionals, andproviding patient services in a range of settings, such asGP clinics, patients’ homes, and coffee shops (AustralianGovernment, Department of Health & Ageing 2010).While the success of the MHNIP rests in the develop-ment of satisfactory working relationships between GPsand mental health nurses, the way in which GPs viewthis ‘new’ partnership with mental health nurses remainsunclear.

Given that the MHNIP is a recent addition to thesuite of programs provided to those with mental health

Correspondence: Tom Meehan, The Park, Centre for MentalHealth, University of Queensland, Locked Bag 500, Richlands, Qld4077, Australia. Email: [email protected]

Tom Meehan, RN, BHSc, MPH, MSocSc, PhD.Samantha Robertson, B BusComm, BAHons.Accepted August 2012.

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International Journal of Mental Health Nursing (2013) 22, 377–383 doi: 10.1111/j.1447-0349.2012.00884.x

© 2012 The AuthorsInternational Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

problems, there have been few published evaluations ofthe program. Happell et al. (2010) interviewed 10 mentalhealth nurses employed in GP clinics and concluded thatthe initiative was adding value in a number of importantways. The nurses provided a holistic approach to patientcare with flexibility in the length of appointment timeand setting for the sessions provided. Some sessions wereconducted in patients’ homes and or other locationsselected by patients (e.g. coffee shops). Perceived out-comes included a reduction in hospital admissions,reduced appointments with GPs and other health profes-sionals, and affordable mental health care (Happell &Palmer 2010). Similarly, Chamberlain-Salaun et al. (2011)interviewed a small sample of GPs and mental healthnurses in North Queensland. The GPs in the sample(n = 7) recognized that they had limited time and skills totreat mental health conditions under the fee-for-servicemodel currently in place. They valued the increasedaccess to treatment for those with mental health problemsprovided through the MHNIP.

An evaluation of a similar program in Canada foundthat GPs reported greater knowledge, better skills, andmore comfort in managing psychiatric disorders (Kiselyet al. 2006). In addition, there was greater satisfactionwith mental health services in general, especially in thearea of having individuals referred/admitted to the mentalhealth system. In a UK study, Bruce et al. (1999) com-pared two GP practices, one with a psychiatric nurse onsite and a comparison practice utilizing a communitymental health team. It was noted that the addition of apsychiatric nurse in the GP clinic improved communica-tion and liaison between service providers (Bruce et al.1999).

This study was designed to explore the way in whichGPs view their working relationship with mental healthnurses. A particular focus of the study was on GP percep-tions of the desired qualities of mental health nurseswishing to work in the general practice setting.

METHOD

The data discussed in this paper forms part of a largerevaluation of the MHNIP conducted between 2008 and2010 in the West Moreton District of Queensland Health.A descriptive study approach using focus group discussionswas employed to generate data for this component of theevaluation. Discussion groups with GPs were conductedmid-way through the evaluation at all seven practicesinvolved in the MHNIP. The study sites included a cross-section of GP practices from both rural and urban areas.The discussion groups (range 40–55 min) were conducted

with between two and five GPs in each group with onediscussion group conducted at each practice. A totalsample of 25 GPs participated in the discussion groups.

ProcedureThe discussion groups were facilitated by a psychologistor mental health nurse who had no involvement in theMHNIP. While the topics discussed were driven by a listof questions set out in a semistructured interview sched-ule, spontaneous feedback was welcomed and encour-aged. Notes were kept during the discussion groups andall groups were audio-taped. The discussion groupsfocussed on the desired qualities of mental health nurseswishing to work in general practice from the perspectiveof GPs. The group discussions were held during lunchtime in each of the practices and all GPs working in thepractice at that time were invited to attend. Of the 31 GPson duty at the time of data collection, 25 participatedin the focus group discussions. The remainder were busywith patients. Ethical approval for the study was obtainedfrom the West Moreton Health Service District EthicsCommittee.

Data analysisAll group discussions were transcribed and checked forerrors against the taped version to ensure accurate andauthentic reproduction. Content analysis (Morse & Field1996) was used to guide data analysis. The transcripts werereviewed several times to acquire a sense of flow and togenerate a list of key ideas and words that reflected thesentiments of the data. Units of information that related tothe same content were brought together and preliminarycategories developed. These were then reviewed by theresearchers for relevance, clarity, and completeness. Find-ings were discussed within the research team and agree-ment was reached on the themes that emerged. Attentionwas given to the limitations of focus group data, and theproblems of inferring consensus, measuring strength ofopinion, and making generalizations, as described by Sim(1998).

RESULTS

Analysis of the data yielded five themes which have impli-cations for policy development and planning. These were:(i) ‘fitting in’; (ii) knowledge; (iii) skills; (iv) supportingGPs; and (v) educating GPs.

Theme 1: ‘Fitting in’‘Fitting in’ had a number of dimensions including fittingin with the culture of the practice, fitting in with the GPs,

T. MEEHAN AND S. ROBERTSON378


and fitting in with the patients. Being flexible and able to‘fit in’ with the routine of the practice was mentioned bya number of the GPs interviewed:

It’s actually quite crucial that they [mental health nurses]work out what the culture of the practice is . . . they willneed to adjust and to fit into the culture and it’s importantthat they make those connections when they start witheveryone.

It was also noted that the nurses would be requiredto fit in with the work ethic of each GP. It was clear fromthe interviews that the level of interest that GPs hadin mental health varied across GPs. It was consideredimportant for the mental health nurse to understand howindividual GPs performed their role and their need forcontact with the nurse:

Some of us [GPs] are not very strong in mental health andare happy for ‘X’ [mental health nurse] to manage theday-to-day care of those patients. Others we have here arewell versed in mental health and will have a more ‘handson’ approach and will want to have more involvement.

Finally, it was identified that the nurses would also berequired to fit in with the needs of the clients and theirfamilies. Patients have a wide range of needs and it wasrecognized that mental health nurses would need to beflexible in their approach when dealing with patients:

There are patients who like to talk and there are those whodon’t say a lot. Being able to quickly assess the patient andsee what they really want from us . . . that’s important.

Theme 2: KnowledgeKnowledge had two dimensions: (i) knowledge of mentalhealth conditions; and (ii) knowledge of local services. Itwas expected that the nurse would have a comprehensiveknowledge of mental health conditions and be competentin assessing patients:

The nurses do help me with diagnosis at times and defi-nitely give me feedback on what’s going on and if there’sanything else that needs to be done, which is good, thenit’s like a team effort and that’s how it should be anyway.

General practitioners expressed a sense of frustrationwhen dealing with mental health services. They identifiedthat obtaining feedback from mental health cliniciansabout patients referred to them took considerable time.Moreover, the feedback provided was frequently briefand they noted that while ‘psychiatrists probably spendhours getting their information, they don’t spend toomuch time writing it down.’ In comparison, mental healthnurses were able to provide feedback that was detailed

and timely and this was seen as being useful as a learningexperience for GPs:

We often discuss patients that both of us have seen andX [nurse] will either confirm my diagnosis or say I don’tagree that, he has such and such. It’s a much better way.Yes, I get a report from the psychiatrist but I usually can’tremember the patient or what they came to see me aboutby the time I get it.

A good understanding of local mental health servicesand the ability to access these when required was alsoconsidered important. The relationship the nurse haddeveloped with the local mental health service was seen asbeing fundamental to the success of the nurses’ role:

The other big issue I used to always have was gettingpeople into the mental health system, to take patientsserious enough in terms that they need admission, etcetera. I think it’s partly an element of trust and people inmental health know the nurses.

It was also recognized that social factors such aslack of appropriate housing, problems with finance,relationships, and lack of social contact added to thecomplexity of presentations to GPs. Knowledge of localsupport services was considered important as GPs feltthat they did not have sufficient information about suchservices:

They [nurses] have the access to resources and can assistthose dysfunctional patients who just need help and it’sbeen really helpful in knowing who to ring and who tocontact to help them, the fact is that I wouldn’t knowwhere to start.

Theme 3: SkillsIn all of the discussion groups conducted, GPs consist-ently noted that nurses need to be caring and not ‘upset’patients through their approach. For example, some GPswere concerned about the questioning of the patient andhow the nurses may cause distress to a patient throughtheir questioning. There was a sense that GPs did notfully understand the skills that the nurses had or tended tounderestimate the ability of mental health nurses to inter-act with patients:

They need to be cautious in working with the patient . . .asking questions and that . . . because sometimes, it’s veryeasy to ask questions, but you don’t know what impact thatcan have on the patient. That can bring up a lot of things . . .past things . . . and you can’t just tell them ‘come back nextweek’ or ‘I’ll give you another appointment’.

General practitioners also highlighted the need forthe nurses to be self-directed and capable of working on

THE MENTAL HEALTH NURSE INCENTIVE PROGRAM 379


their own without constant supervision. It was identifiedthat GPs had limited capacity to supervise nurses:

It’s constant here . . . there’s no let up from the time thedoors open, so the nurses are on their own a lot of thetime . . . they need to be very confident in what they do.

The considerable amount of paperwork associatedwith the program was also raised. GPs questioned theneed for some of this information and how it was utilized:

There’s a lot of paperwork to do and I’m not sure it’s allneeded. They [nurses] have to do the HoNOS [Health ofthe Nation Outcome Scales] tool on each patient they seeas part of the funding agreement but it just sits in the file.Does anyone here actually use it . . . the HoNOS screen?

Theme 4: Supporting GPsAlthough there were some concerns raised about theability of GPs in busy practices to support mental healthnurses, it was clear that the GPs depended on the supportprovided by the nurses:

Just having somebody to share your patient with is reallygood from a day-to-day basis, it’s easier to come to work,it’s easier when you get those patients from when theyfirst open their mouths and burst into tears or if some-thing that would often make your heart sink, you alreadyknow I have somebody else on my side to help me withthis patient and to share this issue and that makes a hugedifference.

Many of the GPs admitted that they did not have theskills or time to deal with patients with more complicatedmental health problems. Indeed, there was a perceptionthat spending time with mental health patients reducedthe time that GPs had for other patients:

It’s actually not well spent time for me because I am notactually adding anything to their treatment, to their mentalhealth . . . it takes time away from my other patients.

However, GPs recognized that the level of supportprovided by the nurses was dependent on the individualnurse. The need for flexibility and finely tuned clinicalskills was noted:

It’s great but like anything it’s operator dependent, itcould be very good or it could be very bad, depending onthe person . . . the nurse . . . you actually get. I mean if itwas an inflexible nurse with little extra to offer, I would bethinking differently about the program.

Theme 5: Educating GPsEducating GPs had two dimensions: (i) educating GPsabout mental health conditions; and (ii) educating GPsabout the MHNIP. In relation to mental health condi-

tions, GPs recognized that most of the nurses had consid-erable knowledge of mental health and current treatmentoptions. They acknowledged that the sharing of informa-tion by the nurses was helping them to keep up to datewith mental health treatment:

Having the nurses here enables us to get information thatis up to date, there are things we don’t deal with enoughin general practice, they know mental health and tosuggest you need to do this and do that.

Turning to the MHNIP, there was considerable varia-tion in GP knowledge of the program. A large proportion ofthose interviewed had difficulty identifying differencesbetween the MHNIP and other similar programs. Indeed,referral decisions appeared to be based on the cost of theprogram rather than other criteria:

I always tell them what we have, we have here theMHN [mental health nurse] and the psychologist, but theproblem with the psychologist is she has a gap fee of $29and most of my patients they do not want to pay that gapfee. So the patient will say I will just see the MHNbecause I cannot pay the gap fee.

It was also clear that a number of GPs did not fullyunderstand the role of the mental health nurse and whatthey had to offer. This was particularly evident in largerpractices that also had a psychologist in residence:

I don’t know what their qualifications are, what do theyknow, what do they do, what’s the difference with regardsto counselling . . . is there something that they cannot dothat the psychologist can do?

Finally, there was also some confusion around thecompletion of mental health plans and this was a sourceof frustration for some GPs. Under the guidelines for theMHNIP, GPs have to develop a Mental Health Plan foreach client referred to the program. Some GPs held theview that the nurses should develop the plan and theywould simply sign off on it. They had difficulty under-standing why this was not considered part of the nurse’srole:

When we have a Diabetic GP Management Plan, weusually have the nurses do up the majority of the plan, andI thought that was what was going to happen with theMental Health Plan too, but apparently not.

DISCUSSION

The MHNIP was established to provide better access tomental health services for those individuals with severemental illness. There has been a rapid expansion of theprogram since it commenced and a growing number



of mental health nurses are now employed with theprogram. While employment in the general practice envi-ronment provides a number of opportunities for mentalhealth nurses, it also presents a range of challenges. Thefindings from this descriptive study highlight some ofthese challenges and provide insights, from the perspec-tive of GPs, into employment in the primary care setting.

The GPs interviewed were very supportive of theprogram and genuinely felt that the approach promotedthrough the MHNIP had enhanced patient care and theirability to manage patients with complex mental healthproblems. Working in close collaboration with mentalhealth nurses resulted in them having more support andoverall confidence to manage psychiatric conditions. Thefindings support earlier UK research which found that theaddition of a psychiatric nurse in the GP clinic improvedcommunication and liaison between service providers andenabled better access to treatment for those with mentalhealth problems (Bruce et al. 1999).

Effective collaboration and working relationshipsbetween mental health and the primary care sectorappear to be based on ‘knowing each other and informa-tion of each other’s competence, systems, possibilities,and restrictions’ (Fredheim et al. 2011; p. 2). However,the findings from this study suggest that many of the GPsinterviewed were unclear about the underlying objectivesof the MHNIP. They did not understand the basic ele-ments of the program, such as the aims of the program,the role of mental health nurses within the program, andthe target group for the program. This lack of awarenesswas surprising given that GPs and nurses were co-locatedwithin the same clinics. Previous research suggests thatmental health nurses need to be assertive when dealingwith GPs and take a lead role in assessment and careplanning (Cartan & Hargie 2004; Happell et al. 2011).However, given that the majority of mental health nursesare employed directly by the GP clinics, there is pressureon nurses to conform and ‘fit in’ with the culture andneeds of their employer.

The need for mental health nurses to be flexible andable to ‘fit in’ with the primary care culture was identified.This seemed to involve an understanding of the ‘implicit’rules around how GPs in particular, and the practice ingeneral, operated. It is clear that many of these ‘rules’reinforced the medical model and the overall dominantposition of the GP within the practice (Happell et al.2011; Olasoji & Maude, 2010). While GPs spoke about apartnership arrangement with mental health nurses, theyrecognized that they (rather than the mental healthnurses) were ultimately responsibility for patient careand decisions related to such care. It is possible that more

experienced nurses may perceive this to be disempower-ing and find it difficult to balance the need to be self-directed with working under the direction and authorityof the GP. It is also possible that some nurses may over-identify with their medical colleagues and have difficultymaintaining a nursing identity within the primary caresetting.

While the MHNIP was established to support GPs inthe management of patients with ‘serious’ mental illness,a large proportion of the GPs interviewed were unawarethat the target group comprised those at the severe endof the scale. During the group discussions, a number ofGPs asked about the most appropriate patients to referto the nurses. This lack of awareness on the part of GPsmay result in inappropriate referrals being made. Indeed,analysis of the quantitative data collected as part of thisevaluation indicates that a proportion of patients referredto the mental health nurses had low HoNOS scores (i.e.low disability). There is a clear need for ongoing educa-tion of GPs in relation to the objectives of MHNIP. Asnoted by Happell et al. (2011), the mental health nursesinvolved in the program have a role to play in promotingthe program to other health professionals, includingGPs. Moreover, the Australian College of Mental HealthNurses should also explore strategies for promoting theprogram to GPs and members of the general public.

It is clear from this and other studies that GPs havelimited time and experience in dealing with mental healthclients (Biddle et al. 2006; McCall et al. 2004; McGawet al. 2006). The GPs who participated in this evaluationhad come to rely on the mental health nurse as a primarysource of mental health information. A solid understand-ing of mental health conditions was therefore seen as animportant attribute of the mental health nurse. The GPsspoke about the partnership arrangement they had withthe nurses but implied that this was built on the ability ofthe nurse to contribute to the assessment and manage-ment of patients with mental health issues.

Concerns were aired about the amount of documenta-tion required for patients enrolled in the program. Forexample, GPs questioned the need to have the HoNOScompleted for each patient. They noted that there wasno training provided to assist them (and mental healthnurses) in the proper use of the measure. Moreover, thepurpose of collecting this data remains unclear as com-pleted measures are placed in the patient’s medicalrecord and do not appear to be used for patient monitor-ing or evaluation. Nonetheless, it was recognized thatnurses would need to balance the time spent seeingpatients with the completion of this paperwork. As oneGP noted, ‘we have one nurse here who is just fantastic



but gets us all in trouble when she cannot seem to com-plete the paperwork.’

Many of the issues highlighted appear to be related tothe rapid implementation of the MHNIP. In 2009, Medi-care Australia reported that in the 2 years since theinitiative commenced, 28 599 people across Australiahad accessed the program and that 136 706 face-to-faceoccasions of services had been provided (AustralianGovernment Medicare Australia 2012). As a result, keycomponents of the MHNIP may not have been fully con-sidered prior to implementation of the program. Forexample, the shortage of nurses with sufficient qualifica-tions to support the program has been identified previ-ously (Olasoji & Maude 2010). Indeed, our findingssuggest that the future viability of the MHNIP maydepend on having an adequate supply of mental healthnurses with sufficient knowledge, skills, and competenceto meet the needs of patients and, also, GPs.

Finally, the results presented here are derived fromdata collected in one region of Queensland. While theattributes of the nurses discussed are likely to be desiredof nurses working under the MHNIP in other regions, adegree of caution is required in generalizing these resultsto a broader population.

CONCLUSION

The findings from this evaluation suggest that the modelpromoted through the MHNIP has enhanced patient careand the ability of GPs to manage patients with complexmental health problems. While mental health nurses areinstrumental to the success of this program, they will needto be flexible and able to fit in with the practice culture,have an in-depth understanding of mental health andlocal services, finely tuned mental health skills, and capac-ity to work collaboratively with GPs. The ongoing successof the initiative will depend on the ability of mental healthnurses to meet the needs of people with severe mentalhealth problems and achieve the commitments outlinedin the policy underpinning the MHNIP. A key factor inthis is ensuring that GPs and mental health nurses areaware of each others roles, capabilities, and restrictions.Future research should explore ways of enhancing GPknowledge of the initiative and identify opportunities thatwill improve communication and learning between GPsand mental health nurses.

ACKNOWLEDGEMENTS

The authors wish to acknowledge the support and fundingprovided by Queensland Health and Janssen-Cilag PtyLtd.

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Mental health nurses working in primary care: Perceptions of general practitioners