Call for hospital nurses to consider patients with both physical and mental illness

A major review calling for better integration of physical and mental healthcare in hospitals has identified a lack of training among acute nurses and other clinicians on psychiatric problems. As a results of its findings, the review recommended that all hospital staff who have interaction with patients should receive training in mental health conditions in general hospitals.

National guidelines should also be developed outlining the expectations of general hospital staff in the management of mental health conditions, such as the point at which a referral to liaison psychiatry should be made and what triggers that referral.

In addition, in order to overcome a divide between mental and physical healthcare, liaison psychiatry services should be fully integrated into general hospitals.

Meanwhile, record sharing – paper or electronic – between mental health hospitals and general hospitals needed to be improved, it said. As a minimum, patients should not be transferred between the two without copies of all relevant notes accompanying the patient, the review said.

According to the in-depth review into over 500 cases, a failure to integrate physical and mental healthcare by hospitals means patients with mental health issues often get poor care.

The report from the National Confidential Enquiry into Patient Outcome and Death said failing to integrate care in this way was disadvantageous for patients with a physical illness who also happened to have a mental health condition. NCEPOD’s Treat as One report was based on an in-depth review into 552 cases involving patients with both a physical illness and a mental health condition.

Researchers looked into the impact a patient’s mental health condition had on the care they received in hospital. Most of the patients had been admitted via emergency departments. Among the key findings were that inadequate mental health history was taken by non-mental health clinicians in 21.4% patients at initial assessment and less than half of patients, 46.3%, had a review by the liaison psychiatry team during their hospital stay. The first assessment by liaison psychiatry was delayed in a third of those seen, which impacted on the quality of care in 22 of the patients reviewed, according to the report. In addition, only around half of hospitals had a liaison psychiatry team available 24/7. Of those patients seen by a liaison team, the reviewers judged their input was adequate in 68.7% of cases.

Meanwhile, less than half of hospitals, 45.7%, had mandatory training in the management of patients with mental health conditions and no hospitals offered training covering all aspects of management of patients with mental health conditions.

As part of the review, around 1,300 health professionals responded to an online survey, which revealed a range of gaps in training on mental health care. For example, 11.4% of respondents said they had no training in basic mental health awareness, 38.9% had no training in management of self-harm and 21.2% had received none on assessing mental health capacity.

In addition, 41.4% had no training on risk assessment, 58.9% had no training in psychotropic medications, and 19.1% had no training in dealing with violence and aggression.

Calling on hospitals to integrate physical and mental health care services as a matter of urgency, report co-author Dr Vivek Srivastava warned that hospital staff often did not have the knowledge or confidence to care for people with mental health conditions appropriately. “Good care was only provided to 46% of patients in this study, showing patients who had a mental health condition suffered the double-whammy of both poor physical and mental healthcare,” he said. “The systems don’t exist to train hospital staff appropriately in the care of patients who also happen to have a mental health condition, so immediately there is an issue with having the confidence to care for this group of patients,” he noted. He added: “Once someone is admitted to hospital it is likely to expose any underlying issue such as a mental health problem, and staff need to have the confidence to deal with this, and have access to and know how to refer to mental health services.”

Dr Srivastava highlighted that, as a direct result of poor physical health care, patients with a mental health condition stayed longer in hospital and also risked being readmitted. “They are often discharged into the community inappropriately and then bounce back in and out of hospital if the underlying health condition is not treated properly,” he said.

NCEPOD chair Professor Lesley Regan agreed that the general hospital workforce, including nurses, had to be educated to understand the gap identified by the review, together with the training and support to have the “competence and confidence to bridge the gap at every level of care”. “This report should be a clarion call that we have a major problem that will be difficult to untangle, and in the meantime we are failing a significant proportion of our patients,” she added.