Two Matrons at Nottinghamshire Health Care NHS Foundation Trust and their teams coordinated and guided improvements in physical healthcare on inpatient mental health wards to improve outcomes, experiences and use of resources across the Trust.
Where to look
Improving life expectancy for people living with mental health conditions is a national priority as described in the Five Year Forward View for Mental Health. This report recommends a focus on supporting people living with severe mental health problems to have their physical health needs met. They should be offered screening and secondary prevention, reflecting their higher risk of poor physical health.
Within Nottinghamshire Health Care NHS Foundation Trust, the Matrons identified that the clinical teams on mental health wards needed to be supported, empowered and trained to address patients’ physical healthcare needs as well as mental health needs appropriately. Unwarranted variation was observed in the physical health support available for the increasing number of patients being admitted to the wards with additional chronic health conditions and comorbidities.
What to change
Nottinghamshire Health Care NHS Foundation Trust offers a wide range of services. These services include services for children, young people, adults of working age and older adults supporting their physical and mental health needs, as well as providing services for those with an intellectual disability. Delivered from over 140 different sites, many of the Trust’s services are community based.
A review of current practice identified that the mental health teams needed support (and training) to meet the physical healthcare needs of their patients, for example pressure ulcer management or diabetes care.
Feedback from staff highlighted that they recognised there was an opportunity to improve practice and were keen to develop their skills and knowledge in the provision of physical healthcare. To support this, a designated team member was appointed ‘Physical Health Matron’ (PHM), who would coordinate and guide improvements by raising the profile of physical healthcare on the inpatient wards, as well as educating and upskilling staff to provide holistic care to patients on the wards.
How to change
A pilot was conducted on two inpatient mental health wards, led by ward managers, inpatient matrons and the wider multidisciplinary team collaboratively. The PHM spent time on the ward getting to know the staff, patients and general day to day routine and through MDT meetings, the PHM developed an enhanced understanding of the challenges of the ward. This combined knowledge supported the overarching provision of physical care input and advice for patients.
The PHM devised a scoping questionnaire which was given to all staff on both wards to rate how confident (scale 1-4) they felt about:
- Their knowledge in relation to certain physical health conditions; and
- Performing a range of physical health tasks/procedures on a day to day basis.
Responses to the questionnaires were analysed and bespoke training and teaching packages were developed and rolled out for staff. The main areas of training needs were pressure area care and diabetes care.
The PHM worked alongside ward staff to support the implementation of enhanced knowledge. Building on the training was a prompt guide for general physical healthcare observations, such as measuring a lying and standing blood pressure or blood glucose testing. The prompt guide has been attached to the blood pressure trolleys on both wards and is easily accessible for staff and students.
The PHM has also supported development of ward discharge pathways for patients and has made links with local community integrated care teams to see what physical health services are available locally for patients. For example, referring to community diabetes nurses to monitor patients in their own home and optimise treatment options. Patients that now require these services are referred prior to discharge.
As part of this programme and pathway refresh, the PHM has reviewed clinical pathways and proformas across the wards and has updated these to reflect current guidelines and align them more with current practice in community services.
To date, the following practice areas have been reviewed, developed and rolled out on the wards:
- Physical observations and recognition of the deteriorating patient – including inclusion of the NEWS tool;
- Pressure ulcer prevention – including use of equipment and tools to identify risk. A checklist has been developed for ward staff to use on discovery of a pressure ulcer, which helps to standardise care;
- Diabetes care – including blood glucose monitoring, medication titration and diabetic foot care; and,
- Integrated care and onward referrals to Integrated Community teams.
Better outcomes – The focused approach to physical healthcare on the mental health wards at the Trust has led to several improved outcomes for patients:
- Patients now receive daily physical observations to identify changes in physical health early to minimise the need for acute hospital admission. This has led to identifying patients at a risk of developing sepsis or increased risk of falling;
- Pressure ulcers have been identified earlier through proactive use of tools, which has meant treatment measures could be implemented in a timely manner to aid wound healing;
- Patients with diabetes are under closer review, which has demonstrated focused management and support for medication use. Staff are also increasingly proactive in identifying symptoms of hyperglycaemia, at times previously undiagnosed; and,
- Patients are now routinely followed up and monitored by a range of community services at discharge to promote and maintain truly holistic care.
Better experience – Staff feedback has been positive regarding the changes, education and training packs, as well as the introduction of new policies, guidelines and prompt guides. Staff report feeling increasingly well-equipped to care for both the physical and mental health of patients. Examples of feedback include:
- “Having a PHM on the ward has been a new experience for all the staff and has helped us navigate training and guidance. They have personally taken the time to teach me about pressure ulcers, and why patients get them and also ways in which they can be treated. This is something which, without them I would of never have been able to do”;
- “During the time that the PHM has been working with us on ward, I have found that my knowledge has increased on physical healthcare. They have provided us with a more in-depth understanding of areas such as pressure ulcer care, wound care, diabetes care”;
- “The PHM has brought their vast knowledge of community services to the MDT which has helped us to maintain the patient’s healthcare the highest standard even after discharge back into the community”.
Patients, their families and carers have also responded well to the new approach to physical care provision across the mental health wards.
Better use of resources – Mental and physical health services working in closer alignment with one another has helped to reduce duplication, through shared learning and experiences. Proactive monitoring of a patient at discharge, from both a physical and mental health perspective, is supporting an ongoing reduction in (re-)admission. Equipment already provided by the Trust is being utilised in everyday practice and staff feel confident and competent in using it.
Challenges and lessons learnt for implementation
Physical and mental health services can work in synergy together to be responsive to patient need. This is also true for multidisciplinary working.
Change can be slow and it takes time to embed new working practices, however don’t forget to reflect on how much you have achieved along the way.
Be determined and clear about what changes you want to influence / change in practice. There will be difficult times during the change process, but keep focused and positive.
Utilising the resources already available, such as the Trust’s Physical Health Care team, is positive e.g. in supporting the delivery of training.
For more information contact
Nottinghamshire Health Care NHS Foundation Trust
Modern Matron (Mental Health)
Nottinghamshire Health Care NHS Foundation Trust