Preventing avoidable inpatient admissions: a qualitative study of mental health liaison nurse practice using the Think Aloud technique. Iain Hepworth Linda McGowan

Introduction Mental health liaison nurses assess people who present at A&E with MH problems requesting inpatient admission. Reduction in mental health inpatient beds. Corresponding increase in home-based treatment. New RAID model.

Background to the study Many mental health NHS trusts are in bed crisis. Increase in use of out of area beds. Pressure on liaison teams not to admit unnecessarily. Little is known about the methods or decision-making processes used by liaison nurses to manage this client group.

Research methods Qualitative study Recruitment: A&E liaison nurses in North of England (n=18). Data collection: Think aloud technique. Followed by semi-structured interviews Framework analysis

Think aloud technique (Ericsson & Simon 1993) Participant is given a task, problem or scenario and encouraged to think aloud during their response to the task. Verbalisation of one’s thoughts whilst performing a task (Fox et al 2011). Four vignettes given to participants.

Findings Four main themes emerge from final framework: 1. Process 2. Expectation management 3. Diversion 4. Pressure

Theme 1. Process – supporting the client Liaison nurses: – Listen and allow the client to ventilate “With some people when you do the assessment if you just spend a little bit of time talking about what’s going on, then that can help them. So, really just giving them a bit of time aside from just doing the risk assessment [Participant 6]”. – Acknowledge and validate. – Problem solving.

Theme 1. Process Reassure and normalise Be honest – “hospital is not going to help you” “In some ways, [admission to hospital] would disable you, if you were admitted. So by taking you out of your environment and putting you somewhere false for one day, two days and then go back home – exactly the same situation; and what have we done for them? Nothing” [Participant 18].

Theme 1. Process - When to say no? “I do tend to tell people very early on in the assessment, I think that’s important I’ve learnt that over the years that if you assess somebody and you leave it right to the very end of an hour and half assessment and say you’re not going to be admitted that’s when the problems are going to start. Get that in quite early on. You can then try and get the client on board what their expectations are, what you can give, what is realistic” [Participant 15]

Theme 1. Process ‘Selling’ the crisis team I know from personal experience that you can’t guarantee someone on a ward an hour of your time because things happen and wards by their nature are constantly changing places, again it would be about selling the crisis team… we sell people on the idea that being at home is better for them, which it clearly is [Participant 4].

Theme 2. Expectation management Clients seeking rest, safety, asylum Hospital Realism – Hospital is disturbed – Not good for people with depression – Does not increase coping skills – No therapeutic benefit – Learn new maladaptive coping behaviours

The unsafe safe-haven paradox of hospital. I would also try and be honest and realistic and say that acute wards can be very disturbed places with very, very sick and unwell people and sometimes it’s not necessarily a calm environment. (Participant 17) Hospital is attractive because it is immediate and instant and you get discharged of all your troubles [Participant 7]

Theme 3. Diversion Before leaving – Liaison nurses seek to ensure – Client leaves feeling better – Client is given something to take with them – There is a care / contingency plan – “Come back and see us”

Theme 4. Pressures Pressure from families Threatened by clients you do get those that say ‘if you don’t admit me, I’m going to do something’ and then it’s about spending more time with a person and not leaving them… get them to the point where they accept, yes, there is an alternative way. Or, they calm down after a while and they accept [Participant 3].

Theme 4. More pressures Lack of emergency planning in care plans Looking for beds “It doesn’t matter if there are twenty beds or no beds; if someone needs admitting then bed numbers don’t even come into my head” [Participant 11]. Lack of training

Summary Liaison nursing is a difficult and challenging. Need enough time and resources to assess. In the absence of training - liaison nurses rely on own knowledge and skills. Need to recruit and retain experienced staff. Further research – client’s perspective? Formalised training?