Handover | Issue 35 – July 2016

Auckland DHB and PHO mental health nurse credentialing

Mental health and addiction training for nurses working in primary care

Auckland Metro district health boards (DHBs) and primary health organisations (PHOs) have demonstrated collaboration for a shared purpose can produce very impressive results. Rachael Calverley, director of nursing and workforce development at Comprehensive Care Ltd (in association with Waitematā PHO) has chaired the “collaborative with a capital C” as she calls it, since it came together 18 months ago. The aim was to develop and deliver a nurse-led mental health and addiction training programme for Auckland nurses working in primary care.

Drawing on the success of mental health training for primary care nurses working at Manaia PHO in Northland, the Auckland group based their training programme on the Te Ao Māramatanga New Zealand College of Mental Health Nurses (NZCMHN) mental health and addiction credentialing framework.

Having done some preliminary work, Procare first brought all the players from the three DHBs and seven PHOs together to agree the basis of the collaborative approach. Fortnightly meetings were held in recognition of the importance of getting the training in place as quickly as possible. Meetings became monthly when study days commenced.

Everyone agreed to put politics aside, and Rachael took a team approach. It was clear that having one consistent programme for nurses across Auckland would use resources in the best way possible. But getting the training up and running was no mean feat, given the size and complexity of Auckland’s population and the built-in tensions between players in a very competitive primary care sector.

From left: Rachael Calverley, RN B.Sc. (Hons) NS MPhil Nursing, director of nursing and workforce development, Comprehensive Care Ltd, Kerri Cantrell, practice nurse at Medplus Medical Centre in Takapuna and Michal Noonan, nurse practitioner at Waitakere Union Health Centre.

Procare employed a project manager, (Jill Moffat), and Rosey Buchan (Comprehensive Care Ltd) to work with Rachael two days a week to help develop the education and liaise with key steering group members with educational expertise, Manaia PHO and NZCMHN.  A number of activities needed to be co-ordinated – bringing everyone
together, engaging all the stakeholders, developing education, selecting supervisors, managing the independent evaluation, and implementing the training itself.

In recognition of the importance of equipping nurses to respond to mental health issues as part of their everyday business all three DHBs had set aside funds for nurse training in primary care. Rachael also spoke of “the tsunami of mental health need on the horizon” identified in both international and New Zealand research, related to our ageing population and other factors. “We need to equip our nurses to manage this,” she says.

She referred to a recent report from the National Nurses Organisation (NNO) suggesting workforce planning for nurses is urgently needed in response to rapid change in the service delivery landscape, and with many nurses nearing retirement age.

Workforce development structures for nurses are not well defined across primary care, and training opportunities can vary quite a bit between GP practices. A key objective was to embed some questions about mental health within all nurse consultations– mainly anxiety and depression. “We can’t keep just leaving it in the too-hard basket”, Rachael explained. One of the key strengths of the course is it meets different levels of need and experience in nursing.

Nurse participants certainly gave the training a big thumbs up, with 91 per cent rating ‘usefulness of the whole programme’ one of the top two ratings on a five point scale used in the evaluation of the course (70 per cent gave it the top rating). Kerri Cantrell, a practice nurse at Medplus Medical Centre in Takapuna, described the course as “a reasonably large learning curve for me” in spite of having over 20 years nursing experience. Describing the course as “pretty full on, informationwise”, she would have liked to have had more opportunity to put the knowledge into practice. She worked out for herself what her changed role would look like, and on reflection, thought it would be good to include ongoing support for a while as part of the course.

Kerri could see the value in getting practice nurses trained in mental health. “It makes so much sense that mental health problems get picked up early and you can stop it developing into something else. And if it stops draining resources down the track, then it’s a win-win situation,” she says.

The training made mental health a priority for Kerri in her own day-to-day nursing practice. She now regularly gets referrals from some of the GPs, mainly for people with symptoms of anxiety and depression. This has increased her workload as it can be time-consuming, but she realises she is making a real difference in people’s lives. “Often it’s just being there, asking simple questions, listening and letting them talk.”

At Kerri’s GP practice if a person is not seriously unwell (such as needing a psychologist or mental health service referral), they are offered a consult with her. These are usually half-hour appointments – some are funded through Care Plus if the person is eligible, otherwise the person does need to meet the costs.

Kerri uses what she has learnt with every consult she does. In doing the course, she realised she has “more of a passion” with mental health, while not wanting to specialise as a mental health nurse. She is now very aware of the difference that can be made to a person’s physical health when they feel well supported with their mental health. This does not always require separate sessions. “You have to address their mental health issues to get anywhere with their diabetes. You have to acknowledge what they are going through mentally before you can make a difference with their weight loss, diet or exercise,” she says. A lot of people just have nobody to support them, and if they have a lot going on physically they don’t cope with things so well. “I spend time listening to them, finding out their needs and giving them strategies to help reduce their anxiety or depression.” She finds that people quickly learn to use the strategies she suggests and are then able to manage themselves.

Other nurses at her practice are keen to have teaching sessions with Kerri, as they realise the difference that can be made. Hopefully this will reduce Kerri’s workload and at the same time provide other nurses with the skills and confidence to better support the mental health of the people they see.

Michal Noonan is a nurse practitioner at Waitakere Union Health Centre, a walk-in clinic in Lincoln Road, Henderson. She mainly works with young people.

“I learned absolutely heaps from the training,” she said. The course has been a real eye-opener to how people with mental health issues are viewed, and also to how they are often treated in primary care. “You can’t really help them in 10 minutes,” she said.

The course gave her the confidence to work with people more effectively, mainly just by asking simple questions such as ‘how are you feeling in yourself?’ She finds having a short conversation can trigger the young person to think differently about what is going on, and work things out for themselves, sometimes through using self-help material on mental health websites like the Lowdown.

Michal is now more likely to use a screening tool like the PHQ9 to better assess the person’s needs, while explaining to the young person why she’s doing this. Then she works out how best to support the person, for example by suggesting they try online cognitive behaviour therapy programmes like SPARX. Part of the course involved meeting people working in some of the local mental health and addiction services and this has made it easier for her to make appropriate referrals, including to Youth Hub, Marinoto, or maternal mental health services.

In some instances she will seek permission from the person to talk to their school nurse, and then follow up to see how it’s going. “We are much better at following up on physical health problems, so why not apply the same approach to mental health issues too?” she says. “The thing that gets me is that I can look up somebody’s HIV status but it’s really hard to access their mental health notes.”

Michal really enjoyed the course and strongly recommends primary care nurses do the training. “The treatments are better, there’s more choices, and it’s such a big problem. We need to be better at it.”

Te Ao Māramatanga (NZCMHN) board member Lois Boyd worked with the Auckland Metro collaborative from late 2015, taking over the credentialing role from Valerie Williams, who had supported the initial programme development. The College works with the hosting organisation to provide guidance and information about key components of the education. Lois worked mainly with Rachael Calverley and Rosey Buchan during this process.

When applicants submit for credentialing to the College, assessors are allocated to check the work against the nurse’s evidence-based record. This can include education sessions they have attended, online programmes completed, evidence of supervision, and the four practice reflections. This is also helpful for the assessors professional development, as they get a greater appreciation of the roles of the nurses.

Lois noted the practice reflections had demonstrated huge benefits to service users. A number of nurses reflected on how “their increased confidence improved their ability to open up conversations rather than shut them down.” This was a theme that came through time and again – the participants felt they were much more useful to people
seeking help.

“Primary care nurses are used to wearing a lot of hats, and if you give them the information they will take it up and use it,” says Lois. Through completing the training, they had now become the ‘go to person’ for mental health and felt they were adding real value to their teams.

In total 27 nurses were supported to translate new knowledge and skills into their practice. Twenty one nurses were based in GP practices. Three were school nurses, two were based in tertiary institutions and one was a public health nurse. The programme included:

  • six study days over a six month period (June-November 2015)
  • ongoing reflective practice
  • a group supervision session (in the period between study days)
  • preparation for credentialing through portfolio presentation to NZCMHN.

The programme aimed to increase nurse confidence, knowledge and understanding. It also helped to reduce stigma and discrimination towards people with mental health and addiction problems, which contributes to relatively poor physical health outcomes. When people are seen primarily for mental health issues, routine screening and identification processes can be overlooked. This is a well-documented phenomenon sometimes described as ‘diagnostic overshadowing’, which can also work the other way, leaving mental health problems unrecognised in people presenting with physical health issues.

The College promotes the credentialing process through its website and local networks. A group in the Bay of Plenty are part way through the training, and in the Hawke’s Bay a group has just started the process. Both groups are smaller local collaborations between the directors of mental health nursing and PHO nurse educators, with
support from DHB staff and the College.

The integration of primary and secondary care services has been on the strategic policy agenda of successive governments since 2001, when the Primary Health Care Strategy was launched. Yet  over the last 15 years, it’s hard to know how much progress there’s been in improving co-ordination across mental health and addiction services, and strengthening the capacity and competency of health care practitioners working in primary care. Other than the evaluation of the Primary Mental Health Initiatives (Dowell et al., 2009) there’s been minimal evaluation of this policy and its implementation. It’s great to see that the Auckland training programme has been independently evaluated (Wyllie, 2016) and the very positive findings made public, as shown in the summary of outcomes below.

On all measures, nurse confidence increased significantly, and new skills and competencies were shown to translate positively into practice. There were many examples of self-reported behaviour change amongst participants. For example, during the four months of the programme, assessment and screening increased by 45 per cent, and
brief intervention and referrals by 100 per cent. There was a 60 per cent increase in participants who reported ‘actively working to reduce stigma and discrimination’ at the two highest levels.

Not surprisingly, a high level of need for the programme was reported by stakeholders who were well aware of government expectations of primary care in this area, and the potential for trained nurses to reduce GP workloads and thereby improve efficiency. Funding was fairly tight. There was no ability to fund replacement nurses (backfill).
However all except three of the participating nurses were being paid while attending the study days, indicating that GP practices could see the potential value of the training.

The evaluation investigated both the collaborative approach, and the impact of the training itself on participating nurses and other stakeholders. It made recommendations on how to improve the programme, and informed a business case for ongoing funding within the Auckland Metro area. The evaluation results argue strongly for
adopting and funding a regional training approach like this across the country, on an ongoing basis.

In Rachael’s words, “it really was the sum of the parts – everyone’s best efforts. I couldn’t have done it without all those brilliant nurse leaders being involved – we all trusted each other that we were on the same page and that was really rewarding.”

The good news is that the training is going to be funded for at least another year. Auckland nurses working in primary care can find out more about enrolling in the next course by contacting Rachael at rcalverley@comprehensivecare.co.nz.