Clinical review
Models of psychiatric consultation liaison nursing Robert Tunmore, Ben Thomas, Bethlem Royal Hospital and Maudsley Hospital, London Recent developments in healthcare legislation have caused nurses to examine new and innovative styles of practice. Psychiatric consultation liaison nursing promotes collaboration among healthcare practitioners, raises standards of patient care and strengthens rather than negates the traditional role of the mental health nurse.
Mr Tunmore is Associate Tutor and Mr Thomas is Chief Nurse Advisor and Director of Quality at the Bethlem Royal Hospital and Maudsley Hospital, Camberwell, London SE5
T
4 L he development of psychiatric con sultation liaison nursing has implications for both nursing practice and education. Not only does this technique contribute to the prevention and detection of mental ill ness and raise the standard of psychological care among patients with physical illness (Tunmore, 1990), but also it may generate revenue as part of a contracted service under purchaser/provider arrangements (Platt-Koch et al, 1990). The report from the Department of Health on services for people with mental illness (DoH, 1990) acknowledges the ef fective use of psychiatric nurses in wards and departments of general hospitals, in cluding accident and emergency depart ments and specialist units such as burns units, renal units, oncology units and mid wifery departments. It also emphasizes the urgent need to prepare nurses for the psy chological and psychiatric impact of acquir ed immunodeficiency syndrome (AIDS). It is encouraging to see that some postbasic nurse education is beginning to include psychiatric consultation liaison nursing, e.g. an English National Board (ENB) 934 certificated course on human immunodeficiency virus (HIV) and AIDS with particular emphasis on mental health issues is running at the Maudsley Hospital (Pirn, 1992). Project 2000: a New Prepara tion for Practice (UKCC, 1986) mentions the consultant nurse, and the International Council of Nurses (1990) suggests consul tation as an aspect of postbasic specialty preparation in psychiatric and mental health nursing. Since the ENB has reported a 50% drop in the numbers of students en tering psychiatric nursing (English Nation al Board, 1992) it may be timely to develop formal education in this respect. The educational aspects of consultation and liaison in clinical practice involve spreading the application of specialist knowledge through the future work of consultées. A small number of consulta
British Journal of Nursing, 1992, Vol 1, No 9
tions have a widespread effect with maxi mum educational impact. While mental health nurses have fewer opportunities for postbasic education (Brooking, 1985) their curricula should incorporate new clinical developments and build up the knowledge base of psychiatric and mental health nurses as preparation for advanced clinical prac tice.
Definitions The terms psychiatric consultation, mental health consultation and liaison psychiatric nursing are often used interchangeably. The American Nurses’ Association (ANA) has taken this one step further and produced a ‘psychiatric consultation-liaison nurse specialist’ (American Nurses Association, 1990). The terms psychiatric nursing and mental health nursing are also used inter changeably or simultaneously to describe the work of the registered mental nurse. However, some authors suggest that they represent two separate world views and competing theories. Thomas (1992) highlights a major dichot omy among psychiatric nurses. One camp holds the view that psychiatric nursing is essentially different from general nursing and has a close affinity with other mental health work. Indeed, some wish to abandon the label of nurse altogether, claiming that their role is associated with treatment rather than care and that psychiatric nursing sits more easily with psychiatry than with gen eral nursing. Pothier et al (1990) subscribe to the view of the psychiatric nurse as men tal health worker rather than an associate of general nursing. The alternative view is that the psychi atric nurse is first and foremost a nurse who happens to work in psychiatry. Hall (1988) argues that if nursing is to be regarded as more than an extension of the medical model then psychiatric and mental health nursing should be consistent with nursing theory development, i.e. it should turn to
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Models of psychiatric consultation liaison nursing ( The term consultation is used to describe a kind o f activity carried out by a person considered authority on a given subject; they are not necessarily authority.
an
’
in
nursing and not to psychiatry for a frame work within which specialist knowledge can be organized. From this perspective the ANA (1990) has produced standards of psychiatric consultation-raison nursing practice. These represent a formalization of work activities and standardization of pro fessional practice. Such a development is seen as worthwhile inasmuch as it provides a systematic approach to service develop ment, recognizes innovative practice, com pares outcomes and measures the quality of care provided. Psychiatric consultation liaison nursing is made up of characteristics from mental health consultation, liaison psychiatry and nursing. These concepts represent comple mentary activities rather than opposing views. Consultation and liaison activities are discussed below in relation to the devel opment of psychiatric and mental health nursing.
Consultation Consultation may be one of several types of activity carried out by a person in auth ority. While the title consultant suggests a specialized professional position of high status it conveys little about consultation as an activity. The term consultation is used to describe a kind of activity carried out by a person considered an authority on a given subject; he/she is not necessarily in authority. Caplan (1970) makes a clear distinction between the process of consultation and the position of the consultant. He describes
how the term consultation denotes a pro cess of interaction between two profes sional persons: the consultant, who is a specialist, and the consultee, who seeks the consultant’s help with regard to a work problem which he believes is within the other’s area of specialized competence. A range of models of consultation have been described including those associated with education, staff development and inservice training, behavioural consultation, and organizational development models in cluding those of the purchaser, the doctorpatient and the process model (Hansen et al, 1990). While models share many com mon characteristics (Table 1) the most ap propriate one is derived from the emphasis and purpose of consultation. Caplan’s model of mental health consultation is most relevant to psychiatric and mental health services (Caplan, 1970).
Caplan’s mode! of mental health consultation Mental health consultation involves the de tection of mental illness and primary, sec ondary and tertiary levels of prevention (Caplan, 1964). The range of consultation operations is organized according to a con ceptual map that indicates limits and boundaries to practice and matches an ap propriate pattern of responses to the situ ation. Caplan describes a fourfold classifi cation with two major divisions based on the main emphasis of the consultation: 1. The primary focus of the consultant may be at the level of either a case problem
Table I. Common characteristics of consultation* Consultants are experts in specialized bodies of knowledge, and most are experts in the process of helping others solve problems. ______________________________________ Consultants work with other individuals to help them resolve work-related problems, but they only focus on consultees’ personal issues as they relate directly to the work situation. _________________________________________________ Consultation is generally an indirect service in which the consultant serves an agency’s clients by working directly with the agency staff. Consultants may meet with clients as a part of the assessment process._______________________________ Consultants are typically outsiders who develop only a temporary relationship with the consultee or organization. There are times when a consultant is employed in the same agency; however, this greatly modifies the consultant’s role and relationships within the organization.____________________________________________________________________ Consultation usually occurs between peers whose areas of responsibility and expertise are different. The relationship is voluntary, and each maintains control over his/her involvement. ___ ______ _____________ Consultees maintain responsibility for any action eventually taken and are free to accept or reject the consultant’s suggestions. ______________________ _______________ *
448
A fter Hansen et al (1990)
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Models of psychiatric consultation liaison nursing or an administrative problem. 2. The route of the consultant’s interven tion may be either direct (provision of a plan or solution) or indirect (by im proving the problem-solving skills of the consultée so that he can find his own solution). Within this classification there are four types of consultation (Fig. 1). In this case the consultant’s primary goal is to ad vise the consultée on the nature of the cli ent’s problems, suggesting a plan of care based on the consultant’s specialist assess ment. A subsidiary goal is the education of the consultée so that he may be able to deal more effectively with similar problems in the future. This type of consultation is typi cal of medical practice and involves the con sultant working directly with the client. In this case education of the consultée is the primary goal. Caplan (1970) identifies four common situations that lead to this type of consultation: 1. Lack of knowledge 2. Lack of skill 3. Lack of self-confidence 4. Lack of professional objectivity. Consultation improves the consultee’s pro fessional functioning, enabling him to solve current work problems. The consultant’s work affects the client indirectly.
Client-centred case consultation:
Consultee-centred case consultation:
Table 2. Five dimensions of consultation* Who
—* Participation
— >
Clients, families, staff
When
—» Timing
->
Prevention, crisis, routine care
Where
-*
How What
->
Level
—> Case consultation, administrative consultation
Route
->
Goal
—» Treatment, programme, policy
Direct, indirect
*A fter Cohn and Smycr (1988)
V "N. ROUTE LEVEL , ------------------------
Direct
Indirect
^
Case consultation
1. Client-centred case consultation
2. Consultee-centred case consultation
Administrative consultation
3. Programme-centred administrative consultation
4. Consultee-centred administrative consultation
Fig. 1. Caplan’s classification of consultation (Caplan, 1970). British Journal of Nursing, 1992, Vol 1, No 9
Programme-centred administrative con sultation: In this case the work problem concerns programme planning and admin istration and draws on the consultant’s skills in administration, social systems, mental health and programme develop ment. The primary goal is analysis of the institution and its mission, identification of short- and long-term solutions to actual and potential problems, and prescription of effective action plans for the consultee’s or ganization. Education of the consultée is a subsidiary goal and the consultant focuses directly on the problem at hand.
Consultee-centred administrative consul tation: This is analogous to consulteecentred case consultation but the consultant addresses the consultee’s difficulties relat ing to programme planning and administra tion. Consultation may be required due to difficulties with interpersonal relationships, e.g. poor leadership, authority problems, lack of role definition and communication blocks, as well as lack of knowledge, skills, self-confidence and objectivity. The inten tion is to educate the consultée so that he will be able to develop and implement ef fective plans by himself. The above framework has been develop ed further by Cohn and Smyer (1988) who identify five dimensions of consultation (Table 2). Each one describes characteristics of the situation, e.g. who makes the request for consultation, who is involved in the work and whether the request comes dur ing a crisis or during a more routine period. Further dimensions include Caplan’s (1970) levels of consultation (case or administra tive consultation and type of involvement, i.c. direct or indirect) and the goals of con sultation. All the dimensions influence each other and need to be considered throughout the consultation process. The consultation process is not dissimilar to the nursing pro cess in that it is based on a problem-solving cycle with different phases (Termini and Ciechoski, 1981).
Liaison Lipowski (1981) defines liaison psychiatry as ‘the diagnosis, treatment, study and pre vention of psychiatric morbidity in the physically ill, of somatoform and factitious disorders, and of psychological factors af fecting physical conditions’. The term li aison emphasizes collaboration with non psychiatric physicians and other healthcare workers, who provide education through clinical service in a variety of settings. This collaboration involves regular contact
449
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Models of psychiatric consultation liaison nursing through participation in care planning. Liaison psychiatry has been used to de note a strategy for providing a clinical ser vice and teaching skills in a specified clinical area for a set number of Hours and also as an abbreviation for consultation liaison psychiatry. The ANA (1990) adopts a simi lar view and states: ‘Liaison refers to the linkage of the knowledge base of psychi atric-mental health nursing and the care of clients/families with actual or potential physical dysfunction in a variety of health care settings’. Lipowski (1981) suggests that the three interrelated functions of liaison (clinical service, education and investigation) are best carried out in the context of consulta tion and that consultation is ‘the corner stone of liaison psychiatry’. Lipowski em phasizes collaborative work, the need for integration to be seen as the most economi cal and effective means of providing a ser vice, and advocates a team approach to li aison, with psychiatrists and nurses, who form the core of the team, being comple mented by social workers and psychol ogists. Caplan (1970) distinguishes the activity of consultation from that of collaboration in the consultant-consultee relationship. Collaboration involves the specialist taking part in implementation of the treatment plan concurrently with his colleague or in successive phases. The specialist’s interven tions are based on his assessment of the cli ent, for whom he has direct responsibility and accountability as far as this treatment is concerned; the procedures involved may
KEY PO INTS • Psychiatric consultation liaison nursing can be developed as an integral part of the role of the mental health nurse. • Postbasic education for mental health nurses needs to incorporate aspects of psychiatric consultation liaison nursing.
have little or no relevance to the work of his colleague. Caplan (1970) identifies simi larities and differences between these activ ities and argues that there is often a need to combine consultation with teaching, supervision and collaboration. Lipowski (1981) discusses collaboration in relation to the different disciplines involved in an in terdisciplinary liaison team.
Conclusion Liaison psychiatry is largely, though not exclusively, based on populations of hospi talized patients. However, Caplan (1964) places greater emphasis on community ser vices. Indeed, mental health consultation developed in North America following changes in legislation and service provision similar to those set out in the Government’s White Paper Caring for People: Commu nity Care in the Next Decade and Beyond (Department of Health, 1989) in that it em phasizes collaborative effort and develop ment. In North America the mental health legislation provided for community services called for more outpatient community mental health clinics, smaller inpatient units, a greater choice of treatments and im proved mental health education and com munity-based prevention programmes. The community mental health movement en couraged the spread of consultation services to individuals and groups as well as to or ganizations such as hospitals, schools, busi nesses and industries (Hansen et al, 1990). Similar developments are occurring in Britain. Recent reports and legislation (De partment of Health, 1989; King’s Fund Commission, 1992) have called for new ways of thinking and new styles of commu nity care. However, psychiatric consulta tion liaison nursing has the potential for de velopment in this country, not as a large expansion of new roles but as a strength ening of the traditional role of the mental health nurse. ]|^ £ î
• The terms consultation and liaison represent a range of activities that need to be defined. • Consultation is efficient in that the educational effects are widespread. • Liaison psychiatry promotes collaborative work among healthcare workers in a variety of settings.
American Nurses Association (1990) Standards o f Psy chiatric Consultation Liaison Nursing Practice. ANA Council on Psychiatric and Mental Health Nursing, Kansas City, Missouri Brooking IJ (1985) Advanced psychiatric nursing edu cation in Britain. J Adv Nurs 10: 455-68 Caplan G (1964) Principles o f Preventive Psychiatry. Basic Books, New York Caplan G (1970) The Theory and Practice o f Mental Health Consultation. Tavistock Publications, Lon don Cohn M, Smyer M (1988) Mental health consultation:
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Models of psychiatric consultation liaison nursing process, professions, and models. In: Smyer M, Cohn M, Brannon D, eds. Mental Health Consul tation in Nursing Homes. New York University Press, New York: 47-63 Department of Health (1989) Caring for People: Com munity Care in the Next Decade and Beyond. HMSO, London Department of Health (1990) Services for People with Mental Illness. Report o f a series o f meetings with heads o f psychiatric nursing services within regional health authorities in England. Department of Health, September 1990: 17—19 English National Board (1992) Appalling drop in men tal health training. Nurs Times 88(21): 6 Firn S (1992) HIV and mental health concerns: the challenges for nursing care. Nurs Times (in press) Hall B (1988) Speciality knowledge in psycniatric nursing: where are we now? Arch Psychiatr Nurs 2(4): 191-9 Hansen J, Himes B, Meier S (1990) Consultation, Con cepts and Practices. Prentice Hall, Cambridge International Council of Nurses (1990) Report on the Status of Psychiatric Nurse Education. World
Health Organization, Geneva King’s Fund Commission (1992) London Health Care 2010: Changing the Future o f Services in the Capi tal. King’s Fund, London Lipowski Z (1981) Liaison psychiatry, liaison nursing and behavioural medicine. Compr Psychiatry 22 (6): 554-61 Platt-Koch L, Gold A, Jocobsma B (1990) Setting up a fee for service program for psychiatric liaison nurses. Clin Nurs Specialist 4(4): 207-10 Pothier P, Stuart G, Puskar K, Baruch K (1990) Dilem mas and directions for psychiatric nursing in the 1990s. Arch Psychiatr Nurs 4(5): 284-91 Termini M, Ciechoski M (1981) The consultation pro cess. Issues in Mental Health Nursing 3: 77-88 Thomas B (1992) Education. In: Brooking J, Ritter S, Thomas B, eds. A Textbook o f Psychiatric and Mental Health Nursing. Churchill Livingstone, London:37-46 Tunmore R (1990) Liaison psychiatry — setting the pace. Nurs Times 186(34): 29-32 UKCC (1986) Project 2000: A New Preparation for Practice. UKCC, London
Instructions to authors for care studies All care studies submitted for publication should be sent to Joy Notter/Paula McGee, Nursing Research Unit, University of Central England in Birmingham, Perry Barr, Birming ham B42 2SU. Studies should be typewritten on A4 paper, double-spaced, and with reasonable margins, on one side of the paper only. Please send three copies.
care given and recommendations for future care (where appropriate). Other disciplines, e.g. psychology, should be included if perti nent as should any specific physiological de tails. Where a specific model of nursing is used, a brief outline of the model should be included (a diagrammatic representation may be help ful) together with a short evaluation including its advantages/disadvantages.
Short introduction/abstract
Confidentiality
This should be approximately 50-100 words You must ensure that whatever other informa identify the pa and should give a precis of the background to tion is included you do the study, the patient’s history, family sup tients), his/her family, home or place of work. port and the clinical setting in which the study occurred.
not
Main text
Overall presentation
Headings should be used where appropriate, and the study should be approximately 2000 words in length. Photographs, charts, tables and/or diagrams should be used to illustrate the main points. Clear indication of where these fit into the text is essential.
The main emphasis should be on the nursing care of the patient(s) and not on the disease process, the surgery carried out, the investiga tions conducted and/or the drugs used. These should be mentioned where appropriate but should not dominate the study. The study should present a comprehensive You must gain the necessary permission to re account of each stage of care: a clear assess produce figures/tables/artwork from other ment of the patient; the aims and plan of care; journals or books before submitting your care a critical evaluation of the effectiveness of the study.
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Models of psychiatric consultation liaison nursing Robert Tunmore, Ben Thomas, Bethlem Royal Hospital and Maudsley Hospital, London Recent developments in healthcare legislation have caused nurses to examine new and innovative styles of practice. Psychiatric consultation liaison nursing promotes collaboration among healthcare practitioners, raises standards of patient care and strengthens rather than negates the traditional role of the mental health nurse.
Mr Tunmore is Associate Tutor and Mr Thomas is Chief Nurse Advisor and Director of Quality at the Bethlem Royal Hospital and Maudsley Hospital, Camberwell, London SE5
T
4 L he development of psychiatric con sultation liaison nursing has implications for both nursing practice and education. Not only does this technique contribute to the prevention and detection of mental ill ness and raise the standard of psychological care among patients with physical illness (Tunmore, 1990), but also it may generate revenue as part of a contracted service under purchaser/provider arrangements (Platt-Koch et al, 1990). The report from the Department of Health on services for people with mental illness (DoH, 1990) acknowledges the ef fective use of psychiatric nurses in wards and departments of general hospitals, in cluding accident and emergency depart ments and specialist units such as burns units, renal units, oncology units and mid wifery departments. It also emphasizes the urgent need to prepare nurses for the psy chological and psychiatric impact of acquir ed immunodeficiency syndrome (AIDS). It is encouraging to see that some postbasic nurse education is beginning to include psychiatric consultation liaison nursing, e.g. an English National Board (ENB) 934 certificated course on human immunodeficiency virus (HIV) and AIDS with particular emphasis on mental health issues is running at the Maudsley Hospital (Pirn, 1992). Project 2000: a New Prepara tion for Practice (UKCC, 1986) mentions the consultant nurse, and the International Council of Nurses (1990) suggests consul tation as an aspect of postbasic specialty preparation in psychiatric and mental health nursing. Since the ENB has reported a 50% drop in the numbers of students en tering psychiatric nursing (English Nation al Board, 1992) it may be timely to develop formal education in this respect. The educational aspects of consultation and liaison in clinical practice involve spreading the application of specialist knowledge through the future work of consultées. A small number of consulta
British Journal of Nursing, 1992, Vol 1, No 9
tions have a widespread effect with maxi mum educational impact. While mental health nurses have fewer opportunities for postbasic education (Brooking, 1985) their curricula should incorporate new clinical developments and build up the knowledge base of psychiatric and mental health nurses as preparation for advanced clinical prac tice.
Definitions The terms psychiatric consultation, mental health consultation and liaison psychiatric nursing are often used interchangeably. The American Nurses’ Association (ANA) has taken this one step further and produced a ‘psychiatric consultation-liaison nurse specialist’ (American Nurses Association, 1990). The terms psychiatric nursing and mental health nursing are also used inter changeably or simultaneously to describe the work of the registered mental nurse. However, some authors suggest that they represent two separate world views and competing theories. Thomas (1992) highlights a major dichot omy among psychiatric nurses. One camp holds the view that psychiatric nursing is essentially different from general nursing and has a close affinity with other mental health work. Indeed, some wish to abandon the label of nurse altogether, claiming that their role is associated with treatment rather than care and that psychiatric nursing sits more easily with psychiatry than with gen eral nursing. Pothier et al (1990) subscribe to the view of the psychiatric nurse as men tal health worker rather than an associate of general nursing. The alternative view is that the psychi atric nurse is first and foremost a nurse who happens to work in psychiatry. Hall (1988) argues that if nursing is to be regarded as more than an extension of the medical model then psychiatric and mental health nursing should be consistent with nursing theory development, i.e. it should turn to
447 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on February 7, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
Models of psychiatric consultation liaison nursing ( The term consultation is used to describe a kind o f activity carried out by a person considered authority on a given subject; they are not necessarily authority.
an
’
in
nursing and not to psychiatry for a frame work within which specialist knowledge can be organized. From this perspective the ANA (1990) has produced standards of psychiatric consultation-raison nursing practice. These represent a formalization of work activities and standardization of pro fessional practice. Such a development is seen as worthwhile inasmuch as it provides a systematic approach to service develop ment, recognizes innovative practice, com pares outcomes and measures the quality of care provided. Psychiatric consultation liaison nursing is made up of characteristics from mental health consultation, liaison psychiatry and nursing. These concepts represent comple mentary activities rather than opposing views. Consultation and liaison activities are discussed below in relation to the devel opment of psychiatric and mental health nursing.
Consultation Consultation may be one of several types of activity carried out by a person in auth ority. While the title consultant suggests a specialized professional position of high status it conveys little about consultation as an activity. The term consultation is used to describe a kind of activity carried out by a person considered an authority on a given subject; he/she is not necessarily in authority. Caplan (1970) makes a clear distinction between the process of consultation and the position of the consultant. He describes
how the term consultation denotes a pro cess of interaction between two profes sional persons: the consultant, who is a specialist, and the consultee, who seeks the consultant’s help with regard to a work problem which he believes is within the other’s area of specialized competence. A range of models of consultation have been described including those associated with education, staff development and inservice training, behavioural consultation, and organizational development models in cluding those of the purchaser, the doctorpatient and the process model (Hansen et al, 1990). While models share many com mon characteristics (Table 1) the most ap propriate one is derived from the emphasis and purpose of consultation. Caplan’s model of mental health consultation is most relevant to psychiatric and mental health services (Caplan, 1970).
Caplan’s mode! of mental health consultation Mental health consultation involves the de tection of mental illness and primary, sec ondary and tertiary levels of prevention (Caplan, 1964). The range of consultation operations is organized according to a con ceptual map that indicates limits and boundaries to practice and matches an ap propriate pattern of responses to the situ ation. Caplan describes a fourfold classifi cation with two major divisions based on the main emphasis of the consultation: 1. The primary focus of the consultant may be at the level of either a case problem
Table I. Common characteristics of consultation* Consultants are experts in specialized bodies of knowledge, and most are experts in the process of helping others solve problems. ______________________________________ Consultants work with other individuals to help them resolve work-related problems, but they only focus on consultees’ personal issues as they relate directly to the work situation. _________________________________________________ Consultation is generally an indirect service in which the consultant serves an agency’s clients by working directly with the agency staff. Consultants may meet with clients as a part of the assessment process._______________________________ Consultants are typically outsiders who develop only a temporary relationship with the consultee or organization. There are times when a consultant is employed in the same agency; however, this greatly modifies the consultant’s role and relationships within the organization.____________________________________________________________________ Consultation usually occurs between peers whose areas of responsibility and expertise are different. The relationship is voluntary, and each maintains control over his/her involvement. ___ ______ _____________ Consultees maintain responsibility for any action eventually taken and are free to accept or reject the consultant’s suggestions. ______________________ _______________ *
448
A fter Hansen et al (1990)
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on February British Journal of Nursing, 1992, Voi l,N7,o2017. 9 Use for licensed purposes only. No other uses without permission. All rights reserved.
Models of psychiatric consultation liaison nursing or an administrative problem. 2. The route of the consultant’s interven tion may be either direct (provision of a plan or solution) or indirect (by im proving the problem-solving skills of the consultée so that he can find his own solution). Within this classification there are four types of consultation (Fig. 1). In this case the consultant’s primary goal is to ad vise the consultée on the nature of the cli ent’s problems, suggesting a plan of care based on the consultant’s specialist assess ment. A subsidiary goal is the education of the consultée so that he may be able to deal more effectively with similar problems in the future. This type of consultation is typi cal of medical practice and involves the con sultant working directly with the client. In this case education of the consultée is the primary goal. Caplan (1970) identifies four common situations that lead to this type of consultation: 1. Lack of knowledge 2. Lack of skill 3. Lack of self-confidence 4. Lack of professional objectivity. Consultation improves the consultee’s pro fessional functioning, enabling him to solve current work problems. The consultant’s work affects the client indirectly.
Client-centred case consultation:
Consultee-centred case consultation:
Table 2. Five dimensions of consultation* Who
—* Participation
— >
Clients, families, staff
When
—» Timing
->
Prevention, crisis, routine care
Where
-*
How What
->
Level
—> Case consultation, administrative consultation
Route
->
Goal
—» Treatment, programme, policy
Direct, indirect
*A fter Cohn and Smycr (1988)
V "N. ROUTE LEVEL , ------------------------
Direct
Indirect
^
Case consultation
1. Client-centred case consultation
2. Consultee-centred case consultation
Administrative consultation
3. Programme-centred administrative consultation
4. Consultee-centred administrative consultation
Fig. 1. Caplan’s classification of consultation (Caplan, 1970). British Journal of Nursing, 1992, Vol 1, No 9
Programme-centred administrative con sultation: In this case the work problem concerns programme planning and admin istration and draws on the consultant’s skills in administration, social systems, mental health and programme develop ment. The primary goal is analysis of the institution and its mission, identification of short- and long-term solutions to actual and potential problems, and prescription of effective action plans for the consultee’s or ganization. Education of the consultée is a subsidiary goal and the consultant focuses directly on the problem at hand.
Consultee-centred administrative consul tation: This is analogous to consulteecentred case consultation but the consultant addresses the consultee’s difficulties relat ing to programme planning and administra tion. Consultation may be required due to difficulties with interpersonal relationships, e.g. poor leadership, authority problems, lack of role definition and communication blocks, as well as lack of knowledge, skills, self-confidence and objectivity. The inten tion is to educate the consultée so that he will be able to develop and implement ef fective plans by himself. The above framework has been develop ed further by Cohn and Smyer (1988) who identify five dimensions of consultation (Table 2). Each one describes characteristics of the situation, e.g. who makes the request for consultation, who is involved in the work and whether the request comes dur ing a crisis or during a more routine period. Further dimensions include Caplan’s (1970) levels of consultation (case or administra tive consultation and type of involvement, i.c. direct or indirect) and the goals of con sultation. All the dimensions influence each other and need to be considered throughout the consultation process. The consultation process is not dissimilar to the nursing pro cess in that it is based on a problem-solving cycle with different phases (Termini and Ciechoski, 1981).
Liaison Lipowski (1981) defines liaison psychiatry as ‘the diagnosis, treatment, study and pre vention of psychiatric morbidity in the physically ill, of somatoform and factitious disorders, and of psychological factors af fecting physical conditions’. The term li aison emphasizes collaboration with non psychiatric physicians and other healthcare workers, who provide education through clinical service in a variety of settings. This collaboration involves regular contact
449
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on February 7, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
Models of psychiatric consultation liaison nursing through participation in care planning. Liaison psychiatry has been used to de note a strategy for providing a clinical ser vice and teaching skills in a specified clinical area for a set number of Hours and also as an abbreviation for consultation liaison psychiatry. The ANA (1990) adopts a simi lar view and states: ‘Liaison refers to the linkage of the knowledge base of psychi atric-mental health nursing and the care of clients/families with actual or potential physical dysfunction in a variety of health care settings’. Lipowski (1981) suggests that the three interrelated functions of liaison (clinical service, education and investigation) are best carried out in the context of consulta tion and that consultation is ‘the corner stone of liaison psychiatry’. Lipowski em phasizes collaborative work, the need for integration to be seen as the most economi cal and effective means of providing a ser vice, and advocates a team approach to li aison, with psychiatrists and nurses, who form the core of the team, being comple mented by social workers and psychol ogists. Caplan (1970) distinguishes the activity of consultation from that of collaboration in the consultant-consultee relationship. Collaboration involves the specialist taking part in implementation of the treatment plan concurrently with his colleague or in successive phases. The specialist’s interven tions are based on his assessment of the cli ent, for whom he has direct responsibility and accountability as far as this treatment is concerned; the procedures involved may
KEY PO INTS • Psychiatric consultation liaison nursing can be developed as an integral part of the role of the mental health nurse. • Postbasic education for mental health nurses needs to incorporate aspects of psychiatric consultation liaison nursing.
have little or no relevance to the work of his colleague. Caplan (1970) identifies simi larities and differences between these activ ities and argues that there is often a need to combine consultation with teaching, supervision and collaboration. Lipowski (1981) discusses collaboration in relation to the different disciplines involved in an in terdisciplinary liaison team.
Conclusion Liaison psychiatry is largely, though not exclusively, based on populations of hospi talized patients. However, Caplan (1964) places greater emphasis on community ser vices. Indeed, mental health consultation developed in North America following changes in legislation and service provision similar to those set out in the Government’s White Paper Caring for People: Commu nity Care in the Next Decade and Beyond (Department of Health, 1989) in that it em phasizes collaborative effort and develop ment. In North America the mental health legislation provided for community services called for more outpatient community mental health clinics, smaller inpatient units, a greater choice of treatments and im proved mental health education and com munity-based prevention programmes. The community mental health movement en couraged the spread of consultation services to individuals and groups as well as to or ganizations such as hospitals, schools, busi nesses and industries (Hansen et al, 1990). Similar developments are occurring in Britain. Recent reports and legislation (De partment of Health, 1989; King’s Fund Commission, 1992) have called for new ways of thinking and new styles of commu nity care. However, psychiatric consulta tion liaison nursing has the potential for de velopment in this country, not as a large expansion of new roles but as a strength ening of the traditional role of the mental health nurse. ]|^ £ î
• The terms consultation and liaison represent a range of activities that need to be defined. • Consultation is efficient in that the educational effects are widespread. • Liaison psychiatry promotes collaborative work among healthcare workers in a variety of settings.
American Nurses Association (1990) Standards o f Psy chiatric Consultation Liaison Nursing Practice. ANA Council on Psychiatric and Mental Health Nursing, Kansas City, Missouri Brooking IJ (1985) Advanced psychiatric nursing edu cation in Britain. J Adv Nurs 10: 455-68 Caplan G (1964) Principles o f Preventive Psychiatry. Basic Books, New York Caplan G (1970) The Theory and Practice o f Mental Health Consultation. Tavistock Publications, Lon don Cohn M, Smyer M (1988) Mental health consultation:
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Models of psychiatric consultation liaison nursing process, professions, and models. In: Smyer M, Cohn M, Brannon D, eds. Mental Health Consul tation in Nursing Homes. New York University Press, New York: 47-63 Department of Health (1989) Caring for People: Com munity Care in the Next Decade and Beyond. HMSO, London Department of Health (1990) Services for People with Mental Illness. Report o f a series o f meetings with heads o f psychiatric nursing services within regional health authorities in England. Department of Health, September 1990: 17—19 English National Board (1992) Appalling drop in men tal health training. Nurs Times 88(21): 6 Firn S (1992) HIV and mental health concerns: the challenges for nursing care. Nurs Times (in press) Hall B (1988) Speciality knowledge in psycniatric nursing: where are we now? Arch Psychiatr Nurs 2(4): 191-9 Hansen J, Himes B, Meier S (1990) Consultation, Con cepts and Practices. Prentice Hall, Cambridge International Council of Nurses (1990) Report on the Status of Psychiatric Nurse Education. World
Health Organization, Geneva King’s Fund Commission (1992) London Health Care 2010: Changing the Future o f Services in the Capi tal. King’s Fund, London Lipowski Z (1981) Liaison psychiatry, liaison nursing and behavioural medicine. Compr Psychiatry 22 (6): 554-61 Platt-Koch L, Gold A, Jocobsma B (1990) Setting up a fee for service program for psychiatric liaison nurses. Clin Nurs Specialist 4(4): 207-10 Pothier P, Stuart G, Puskar K, Baruch K (1990) Dilem mas and directions for psychiatric nursing in the 1990s. Arch Psychiatr Nurs 4(5): 284-91 Termini M, Ciechoski M (1981) The consultation pro cess. Issues in Mental Health Nursing 3: 77-88 Thomas B (1992) Education. In: Brooking J, Ritter S, Thomas B, eds. A Textbook o f Psychiatric and Mental Health Nursing. Churchill Livingstone, London:37-46 Tunmore R (1990) Liaison psychiatry — setting the pace. Nurs Times 186(34): 29-32 UKCC (1986) Project 2000: A New Preparation for Practice. UKCC, London
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