Early warning scores What can mental health nurses do to meet older patients’ physical health needs?
Sarah McGeorge is nurse consultant, Lesley Chapman is physical care practitioner and Paula Atkinson is advanced nurse practitioner – liaison, all at Mental Health Services for Older People, Tees, Esk and Wear Valleys NHS Foundation Trust
This is an interesting and important question of national concern. Responses to the consultation on the Chief Nursing Officer’s Review of Mental Health Nursing (Department of Health 2006) and the Royal College of Psychiatrists’ (2009) report noted that people with mental health problems often receive less than adequate care for their physical health. Physical health problems, particularly chronic health problems such as obesity, diabetes and smoking-related illnesses, are more common in people with long-term mental illness.
A further complication for mental health nurses working with older people is the altered presentation of illness in older age, sometimes accompanied by the person’s inability to express how they are feeling or explain symptoms that can make it more difficult to recognise physical illness.
Detection of physical illness can therefore require a combination of observational skills, deduction and intuition, but there are tools that nurses can use to help. Awareness of a person’s ‘usual state’ is the foundation for recognising any illness.
Mental health nurses are familiar with gathering baseline information about a person’s psychiatric symptoms, functional ability and behaviour from the person as well as from other people who know the person well. However, they may be less accustomed to routinely collecting physiological measurements such as pulse and blood pressure. These measurements are essential in detecting change in a person’s physiological state and therefore detecting early signs of physical illness.
One example of how to raise awareness about older patients’ physical health needs and improve practice comes from the authors’ work on patient safety. Prompted by the National Institute for Health and Clinical Excellence (2007) guideline on acutely ill patients in hospital, we developed an early warning score (EWS) system. These are common in acute hospitals, but we could not find any examples of their use in mental health wards.
We adapted and piloted a tool in our service and have now implemented it on all wards. Every inpatient has daily physiological observations recorded on the EWS chart. The chart is colour-coded to help nurses make decisions about what action is required as a result of the patient’s score. Two senior nurses provided training for ward nurses in recording physiological observations as well as how to use the system. Training included observed practice. Re-audit has shown improvement in practice, but there is still room for further improvement and our training plan continues.
We have gathered case examples to demonstrate that the system helps nurses to make decisions, for example, when to call a doctor or when to call 999, and ambulance service staff have found the information that nurses are able to provide has enabled them to make appropriate responses. Nurses who are using the EWS system report that they feel much more confident in making decisions about patients’ physical care. Over time we hope to reduce the number of patients who have unnecessary transfers to an acute hospital; this experience is often counterproductive to the patient’s mental wellbeing as well as contributing to pressures in acute hospitals.
Mental health nurses may think that they lack knowledge and skills in promoting physical health, particularly as patients admitted to mental health wards for older people are increasingly frail and likely to have multiple comorbidities. Our service has invested in a physical care practitioner post to improve the care provided to patients, but it is also possible to work with colleagues from primary care or acute hospitals to enhance skills and knowledge in this area. Mental health nurses should see physical care as an integral part of their role and identify their own training needs through supervision and appraisals. In this way we can begin to redress the imbalance and improve care for patients who have mental and physical illnesses.
Department of Health (2006) Chief Nursing Officer’s Review of Mental Health Nursing. Summary of Responses to the Consultation. DH, London.
National Institute for Health and Clinical Excellence (2007) Acutely Ill Patients in Hospital. Recognition of and Response to Acute Illness in Adults in Hospital. Clinical Guideline 50. NICE, London.
Royal College of Psychiatrists (2009) Physical Health in Mental Health. Final Report of a Scoping Group. Occasional Paper OP67. RCP, London.
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