supporting the mental health needs of people living with ...€¦ · project officer, rdns helen...

Supporting the mental health needs of people living with HIV/AIDS in a community nursing environment

Supporting the Mental Health Needs of People

Living with HIV/AIDS in a Community Nursing

Environment

Final Report

December 2007

Report prepared by:

Jacqui Allen (RDNS Institute)

Adam Hamilton (Mental Health, Drug & Alcohol Clinical Nurse Consultant HIV/AIDS)

Russell Nunn (RDNS Institute)

Liz Crock (Clinical Nurse Consultant HIV/AIDS)

Judy Frecker (Clinical Nurse Consultant HIV/AIDS)

Nalla Burk (Clinical Nurse Consultant HIV/AIDS)

Page 0

Published by:

Helen Macpherson Smith Institute of Community Health

Royal District Nursing Service

Melbourne, Australia

© ROYAL DISTRICT NURSING SERVICE 2007

No part of this publication may be reproduced, copied or transmitted unless done so with the written permission from the publisher or in accordance with the provisions of the Australian Copyright Act.

ii

Acknowledgements

The authors of this report would like to gratefully acknowledge the contribution of the following:

• The Victorian Department of Human Services Metropolitan Health and Aged Care Services HIV Community Grants for funding the project

• The RDNS Helen Macpherson Smith Institute of Community Health (RDNS Institute) for the provision of a substantial amount of in-kind support and resources to conduct the evaluation of the project

• Martin Wischer (RDNS General Manager Director Of Nursing - South & East) for his support throughout the project

• Terry Gliddon (RDNS Research & Development Manager) and Lisa Donohue (Acting General Manager – RDNS Institute) for their support throughout the project and for their comments on the final report

• Karyn Gellie, RDNS Homeless Person’s Programme, Mary Hartwig, Lawrence Cameron and Liz Craig (former HIV Team members) who contributed to the original proposal

• All RDNS staff and external service providers who participated in the project

• All RDNS clients who participated in the project

iii

Project Team

Martin Wischer General Manager Director of Nursing South and East Regions

Jacqui Allen Project Officer, RDNS Helen Macpherson Smith Institute of Community Health

Nalla Burk Clinical Nurse Consultant HIV/AIDS Team

Liz Crock Clinical Nurse Consultant HIV/AIDS Team

Judy Frecker Clinical Nurse Consultant HIV/AIDS Team

Terry Gliddon Manager – Research and Development

Adam Hamilton Mental Health Drug and Alcohol Clinical Nurse Consultant HIV/AIDS Team

Russell Nunn Researcher, RDNS Helen Macpherson Smith Institute of Community Health

Maureen Wilkinson Centre Manager – Altona Centre

Barbara Williams Mental Health Clinical Nurse Consultant – North & West Regions

iv

Table of Contents PROJECT TEAM .................................................................................................................................................IV

TABLE OF CONTENTS ...................................................................................................................................... V

LIST OF TABLES AND FIGURES .................................................................................................................VIII

1 EXECUTIVE SUMMARY ......................................................................................................................... 1 1.1 INTRODUCTION ...................................................................................................................................... 1

1.1.1 Project Aim ....................................................................................................................................... 1 1.2 METHODS .............................................................................................................................................. 1 1.3 CLIENT PROFILE..................................................................................................................................... 2 1.4 DEVELOPMENT OF THE HIV/AIDS MENTAL HEALTH DRUG AND ALCOHOL CLINICAL NURSE CONSULTANT ROLE ............................................................................................................................................ 2 1.5 EVALUATION FINDINGS ......................................................................................................................... 3

1.5.1 Case and Demographic Data ........................................................................................................... 3 1.5.2 Quantitative Client Outcome Data ................................................................................................... 3 1.5.3 Qualitative Client Outcome Data (Interviews) ................................................................................. 4 1.5.4 Survey Data (Clients) ....................................................................................................................... 5 1.5.5 Qualitative Data (Focus Group with RDNS Nurses and Social Workers)........................................ 5 1.5.6 Phone Interview Data (External Service Providers) ....................................................................... 6

1.6 DISCUSSION AND CONCLUSION.............................................................................................................. 6 1.7 RECOMMENDATIONS.............................................................................................................................. 7

2 INTRODUCTION ..................................................................................................................................... 10 2.1 RDNS HIV/AIDS MODEL OF CARE .................................................................................................... 10 2.2 THE NEED FOR THE HIV/AIDS MENTAL HEALTH AND DRUG AND ALCOHOL CLINICAL NURSE CONSULTANT ROLE .......................................................................................................................................... 12 2.3 PROJECT AIM ....................................................................................................................................... 14 2.4 PROJECT OBJECTIVES........................................................................................................................... 14 2.5 ANTICIPATED OUTCOMES .................................................................................................................... 14

3 METHODS................................................................................................................................................. 16 3.1 PHASE 1 ORIENTATION & ASSESSMENT............................................................................................... 17

3.1.1 Orientation of Mental Health Drug and Alcohol CNC................................................................... 17 3.1.2 Identification and Review of Current Practices.............................................................................. 17 3.1.3 Profile of HIV/AIDS Program Clients ............................................................................................ 17 3.1.4 Literature Review............................................................................................................................ 17 3.1.5 Selection of Screening Tools........................................................................................................... 17

3.2 PHASE 2 PLANNING.............................................................................................................................. 18 3.2.1 Development/Modification of MH Assessment Tool ....................................................................... 18 3.2.2 Documentation of Project Methods ................................................................................................ 18 3.2.3 Design of Questionnaires and Interview Guidelines ...................................................................... 18 3.2.4 Submission to RDNS Research Ethics Committee (REC) ............................................................... 18 3.2.5 Finalise Methods in Relation to RDNS REC Requirements............................................................ 18

3.3 PHASE 3 IMPLEMENTATION & EVALUATION ........................................................................................ 18 3.3.1 Client Recruitment and Collection of Client Demographic, Case and Outcome Data................... 19 3.3.2 Client and Carer Surveys................................................................................................................ 21 3.3.3 Client and Carer Interviews ........................................................................................................... 22 3.3.4 Focus Group Interview ................................................................................................................... 23 3.3.5 Phone Interviews ............................................................................................................................ 24

3.4 PHASE 4 ANALYSES ............................................................................................................................. 24 3.5 PHASE 5 WRITING OF FINAL REPORT ................................................................................................... 25 3.6 ETHICAL ISSUES................................................................................................................................... 25

3.6.1 Recruitment of Clients and Carers ................................................................................................. 25 3.6.2 Social, Cultural, Linguistic, ‘Other’ Sensitivities of Client Group................................................. 26 3.6.3 Recruitment of Community Nurses ................................................................................................. 26

v

3.6.4 Recruitment of External Service Providers..................................................................................... 26 3.6.5 Privacy & Confidentiality ............................................................................................................... 27

4 PROFILE OF RDNS CLIENTS LIVING WITH HIV/AIDS................................................................ 28 4.1 METHOD .............................................................................................................................................. 28 4.2 RESULTS .............................................................................................................................................. 29

4.2.1 Demographic Characteristics......................................................................................................... 29 4.2.2 Treating Centre............................................................................................................................... 31 4.2.3 Source of Referral for RDNS Clients living with HIV/AIDS........................................................... 31 4.2.4 Mental Disorder and Drug and Alcohol Disorder Diagnoses........................................................ 33 4.2.5 Visit Information............................................................................................................................. 37

4.3 DISCUSSION ......................................................................................................................................... 38 5 DEVELOPMENT OF THE HIV/AIDS MENTAL HEALTH AND DRUG AND ALCOHOL CLINICAL NURSE CONSULTANT ROLE................................................................................................... 40

5.1 LITERATURE REVIEW........................................................................................................................... 40 5.1.1 Definitions of the Consultation Liaison Psychiatry Nursing Role .................................................. 40 5.1.2 Investigations of the Effectiveness of the Consultation Liaison Psychiatry Nursing Role.............. 41 5.1.3 Effectiveness of Drug and Alcohol Nursing Roles .......................................................................... 43

5.2 HIV/AIDS CLINICAL NURSE CONSULTANT MENTAL HEALTH AND DRUG AND ALCOHOL ROLE ........ 43 6 EVALUATION FINDINGS ....................................................................................................................... 46

6.1 CASE AND DEMOGRAPHIC DATA ......................................................................................................... 46 6.2 SCREENING AND REFERRAL DATA....................................................................................................... 51 6.3 NURSING ASSESSMENT ........................................................................................................................ 52

6.3.1 Mental Health Drug and Alcohol CNC Activities........................................................................... 54 6.4 CLIENT ASSESSMENT AND FOLLOW-UP DATA ..................................................................................... 55

6.4.1 Depression Anxiety and Stress Scales (DASS21)............................................................................ 56 6.4.2 Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)........................................ 58 6.4.3 Health of the Nations Outcomes Scales (HONOS) ......................................................................... 60 6.4.4 Quality of Life (WHOQoL bref)...................................................................................................... 61

6.5 CLIENT SATISFACTION FINDINGS......................................................................................................... 62 6.5.1 Client Satisfaction........................................................................................................................... 62

6.6 CLIENT INTERVIEWS ............................................................................................................................ 66 6.6.1 Theme analysis................................................................................................................................ 66

6.7 FOCUS GROUP INTERVIEW ................................................................................................................... 68 6.7.1 Theme analysis................................................................................................................................ 68

6.8 PHONE INTERVIEWS ............................................................................................................................. 72 6.8.1 Theme analysis................................................................................................................................ 72

7 DISCUSSION............................................................................................................................................. 76 7.1 CASE AND DEMOGRAPHIC DATA ......................................................................................................... 76 7.2 SCREENING AND REFERRAL DATA....................................................................................................... 76 7.3 NURSING ASSESSMENT ........................................................................................................................ 77 7.4 CLIENT ASSESSMENT AND FOLLOW-UP DATA ..................................................................................... 77

7.4.1 Depression Anxiety and Stress Scales (DASS21)............................................................................ 78 7.4.2 Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)........................................ 78 7.4.3 Health of the Nations Outcomes Scales (HONOS) ......................................................................... 78 7.4.4 Quality of Life (WHOQOL bref) ..................................................................................................... 79

7.5 CLIENT AND CARER SURVEY DATA ..................................................................................................... 79 7.5.1 Client Surveys ................................................................................................................................. 79 7.5.2 Carer Surveys ................................................................................................................................. 80

7.6 CLIENT INTERVIEWS ............................................................................................................................ 80 7.7 FOCUS GROUP INTERVIEW ................................................................................................................... 80 7.8 PHONE INTERVIEWS ............................................................................................................................. 81 7.9 LIMITATIONS........................................................................................................................................ 82

8 CONCLUSION ........................................................................................................................................... 84

9 RECOMMENDATIONS........................................................................................................................... 85

vi

REFERENCES.................................................................................................................................................... 88

APPENDICES..................................................................................................................................................... 91 Appendix A – MMSE.................................................................................................................................... 92 Appendix B – Client Cognitive Capacity Checklist...................................................................................... 94 Appendix C – Plain Language Statement (Client) ....................................................................................... 95 Appendix D – Consent Form (Clients)......................................................................................................... 97 Appendix E – Consent Form (on behalf of the client).................................................................................. 98 Appendix F – K10 ........................................................................................................................................ 99 Appendix G – DASS21 ............................................................................................................................... 100 Appendix I – HONOS................................................................................................................................. 113 Appendix J – WHOQoL-BREF .................................................................................................................. 114 Appendix K – Satisfaction Survey (Clients) ............................................................................................... 117 Appendix L – Interview Guidelines (Clients & Carers) ............................................................................ 121 Appendix M – Plain Language Statement (Staff Focus Group)................................................................. 122 Appendix N – Consent Form (Staff Focus Group)..................................................................................... 124 Appendix O – Staff Focus Group Interview Guidelines............................................................................. 125 Appendix P – Plain Language Statement (External Providers)................................................................. 127 Appendix Q – Consent Form (External Providers).................................................................................... 129 Appendix R – Phone Interview Guidelines (External Providers)............................................................... 130 Appendix S – Transcribers Declaration of Confidentiality........................................................................ 131

vii

List of Tables and Figures

Tables:

Table 3-1 Project Timeline ................................................................................................................... 16

Table 4-1 Country of Origin for Clients Living with HIV/AIDS (N=141) .......................................... 30

Table 4-2 Carer Availability for Clients Living with HIV/AIDS (N=141) .......................................... 30

Table 4-3 Living Arrangements for Clients Living with HIV/AIDS (N=141) ..................................... 31

Table 4-4 Frequency of Episodes Involving Clients Living with HIV/AIDS by RDNS Centre (N=141)...................................................................................................................................................... 32

Table 4-5 Source of Referral to RDNS for Episodes Involving Clients Living with HIV/AIDS (N=141) ........................................................................................................................................ 32

Table 4-6 Mental Disorder and Drug and Alcohol Disorder Diagnoses for Client Care Episodes Involving Clients Living with HIV/AIDS and a Mental Disorder/s (n=89)* .............................. 34

Table 4-7 Demographic Characteristics by Mental Disorder and Drug and Alcohol Disorder Diagnoses (N=141) ...................................................................................................................... 34

Table 4-8 Carer Availability by the Top Five Mental Disorder and Drug and Alcohol Disorder Diagnoses (N=141) ...................................................................................................................... 35

Table 4-9 Living Arrangements by the Top Five Mental Disorder and Drug and Alcohol Disorder Diagnoses (N=141) ...................................................................................................................... 36

Table 4-10 RDNS Staff Type by Frequency of Client Care Visits Involving Clients Living with HIV/AIDS (n=13,703) ................................................................................................................. 37

Table 4-11 RDNS Visit Activity by Frequency of Client Care Visits Involving Clients Living with HIV/AIDS (n=12,365) ................................................................................................................. 38

Table 6-1 Outcome of selection and recruitment processes (N=119)................................................... 47

Table 6-2 Age and gender (N=119) ...................................................................................................... 48

Table 6-3 Country of origin (N=119) ................................................................................................... 48

Table 6-4 Carer availability (N=119).................................................................................................... 49

Table 6-5 Living Arrangements (N=119) ............................................................................................. 49

Table 6-6 Frequency of Mental Disorders (N=119) ............................................................................. 50

Table 6-7 Frequency of Type of Mental Disorder (N=119) ................................................................. 50

Table 6-8 Frequency and Type of Nursing Activities (N=119)............................................................ 51

Table 6-9 Clinical Caseness for K10 and MMSE (n=43) ..................................................................... 52

viii

ix

Table 6-10 Past mental health/substance use diagnosis (n=43) ............................................................ 53

Table 6-11 Past mental health/substance use treatment (n=43) ............................................................ 53

Table 6-12 Current mental health/substance use diagnosis (n=43) ...................................................... 53

Table 6-13 Current mental health/substance use treatment (n=43) ...................................................... 54

Table 6-14 Mental Health Drug and Alcohol CNC interventions (n=43) ............................................ 55

Table 6-15 Referrals to external providers/services (n=43).................................................................. 55

Table 6-16 Correlations for the K10 and Assessment Measures - DASS21, ASSIST, HONOS and WHOQoL-bref (n=43) ................................................................................................................. 57

Table 6-17 Mean scores for DASS21 collected at assessment and follow-up (n=41).......................... 58

Table 6-18 Scores above cut off for DASS21 collected at assessment and follow-up (n=41) ............. 58

Table 6-19 Descriptive statistics for people using alcohol and/or drugs at assessment and follow-up (n=41)........................................................................................................................................... 59

Table 6-20 Mean scores for ASSIST at assessment and follow-up (n=41) .......................................... 59

Table 6-21 Scores above cut off for ASSIST at assessment and follow-up (n=41).............................. 60

Table 6-22 Mean scores for HONOS collected at assessment and follow-up (n=41) .......................... 60

Table 6-23 Scores above cut off for HONOS collected at assessment and follow-up (n=41).............. 61

Table 6-24 Mean scores for WHOQOL bref at assessment and follow-up (n=41) .............................. 62

Table 6-25 The best feature of the Mental Health Drug and Alcohol Clinical Nurse Consultant service (n=25)........................................................................................................................................... 63

Table 6-26 Suggested improvements to the Mental Health Drug and Alcohol Clinical Nurse Consultant service (n=25) ............................................................................................................ 64

Table 6-27 Responses to the Client Satisfaction Survey at Follow-up (n=25) ..................................... 65

Figures:

Figure 4-1 Age Distribution of Clients Living with HIV/AIDS (N=141) ............................................ 29

Figure 6-1 Age Range in Years for all RDNS Clients on the HIV/AIDS Program.............................. 46

1 Executive Summary

1.1 Introduction RDNS has been providing care to people living with HIV/AIDS since 1985. Given the high prevalence of mental health and drug and alcohol problems amongst RDNS HIV/AIDS clients, the trial of a Mental Health Drug and Alcohol Clinical Nurse Consultant as part of the HIV/AIDS Team (Mental Health Drug and Alcohol CNC) is a vital and timely addition to RDNS services.

The Mental Health Drug and Alcohol CNC role was trialled and developed over the 12-month project within the existing RDNS HIV/AIDS Team of three Clinical Nurse Consultants. The development and refinement of this role was also informed by findings from an evaluation study focused on client outcomes. It was anticipated that multiple benefits for clients would ensue from the trial of the Mental Health Drug and Alcohol CNC role as a result of focused assessment and enhanced treatment planning such as: reduced likelihood of hospitalisation/use of emergency services due to relapse and mental health crises; improved social functioning, and better adherence with medical treatment regimes. Other anticipated benefits included strengthening and increasing RDNS’ capacity to provide optimal care for clients with HIV and co-morbid mental health, drug and alcohol problems; and in providing education and support to wider community groups assisting people living with HIV/AIDS including the Victorian AIDS Council Community Support Programme.

1.1.1 Project Aim

To develop, trial and evaluate a Mental Health Drug and Alcohol CNC role for optimal community nursing care of RDNS clients living with HIV/AIDS.

1.2 Methods The methods for this project involved a phased approach to:

• Orientate the Mental Health Drug and Alcohol CNC

• Develop referral and assessment systems

• Undertake a profile of RDNS clients living with HIV/AIDS

• Document the methods including selecting/developing all data collection tools, and obtaining approval from the RDNS Research Ethics Committee

• Implement and evaluate the role

• Undertake data analyses

• Write the final report.

Data collection systems comprised:

• Case and demographic data

• Quantitative client outcome data captured at assessment and 6-8 weeks follow-up including the Depression Anxiety and Stress Scales 21 item version (DASS21), the

1

• Qualitative client outcome data (interview data)

• Survey data (clients and carers)

• Qualitative data (focus group with RDNS nurses and social workers)

• Phone interview data (external service providers)

1.3 Client Profile Findings from the profile of RDNS clients with HIV/AIDS over the 2006 calendar year indicate that mental health and drug and alcohol disorders are highly prevalent among this client group. A significant number (63.1%) of these people had a mental disorder and/or drug and alcohol disorder recorded. This is over three times greater than that found for all RDNS clients (18.8%) in the client profile undertaken as part of the RDNS Model of Mental Health Care project (Nunn & Allen, 2006). The most frequently occurring diagnoses were depression, anxiety and non dependent drug abuse1.

Demographic data suggest that most in this client group are in their early 40s, are male, and were born in Australia. However, this is also a very diverse and complex client group with a significant number of clients being born in countries other than Australia and many having Aboriginal or Torres Strait Islander backgrounds. In addition, there is a disproportionate number of female clients receiving care from the RDNS HIV/AIDS Team. Carer availability and living arrangements data indicate that many of these clients live alone with no carer, or do not require a carer, with almost half of these clients living alone. Similarly, living arrangement and carer availability data for those clients living with HIV/AIDS with co-morbid depression, anxiety and/or non dependent drug abuse reveals that approximately one half live alone and approximately one quarter live alone with no carer.

1.4 Development of the HIV/AIDS Mental Health Drug and Alcohol Clinical Nurse Consultant Role

Within the context of the current project, the Mental Health Drug and Alcohol CNC is an advanced practice nursing role that has the potential to add a specialist stratum of mental health and drug and alcohol nursing expertise to meet the highly complex and multifaceted care needs of the RDNS HIV/AIDS client group. It is common for RDNS clients with HIV/AIDS to experience co-occurring mental health and/or drug and alcohol problems leading to multiple challenging and complex health needs and increasing the burden on acute care services when health crises arise. Although the RDNS HIV/AIDS Team Clinical Nurse Consultants are expert in nursing care provision for people living with HIV/AIDS, they do not necessarily have qualifications in mental health and/or drug and alcohol nursing. Additionally, most RDNS field staff are generalist registered nurses with limited experience in providing mental health and drug and alcohol care such as focused assessment and care plan formulation. Therefore, a Clinical Nurse Consultant with the appropriate educational preparation and experience in mental health and drug and alcohol nursing is an important addition to the RDNS HIV/AIDS Team in order to provide a direct clinical care service to clients and to liaise closely with RDNS nurses to support them in care provision.

1 In accordance with ICD-9 terminology, the term “drug abuse” is used throughout the current report.

2

Importantly, the mental health drug and alcohol nursing role is a community health nursing role. In addition to being based in the community, it functions in accordance with the primary health care principles of partnership and collaboration, and targets social determinants of health and illness, in particular social factors known to negatively affect health and wellness such as poor housing and stigma which impede access to health services. Furthermore, the Mental Health Drug and Alcohol CNC role is focused on proactive management of health and social crises such as those related to suicide risk, challenging behaviours, stigma and discrimination.

Other domains relevant to the role comprise:

• Enhanced identification of mental health and drug and alcohol use problems for HIV/AIDS clients via screening and assessment, including risk assessment. (especially with regard to mental illness, suicide risk assessment and drug and alcohol use).

• Improved management of related health and social problems.

• Enhancement of clients’ capacity to remain in the community.

• Improved liaison with and care coordination across diverse health and social services such as mental health services, drug and alcohol services and services focused on HIV/AIDS issues.

• Provision of an outreach service to people living with HIV/AIDS maximising access to mental health and drug and alcohol services and targeting early identification and prevention of health and social crises related to mental health and drug and alcohol difficulties.

1.5 Evaluation Findings

1.5.1 Case and Demographic Data

During the four month client recruitment period, a total of 119 clients were receiving care on the HIV/AIDS Program - 43 (36%) agreed to participate, 44 (37.0%) declined and 32 (26.9%) did not meet the selection criteria. Most clients who agreed to participate were males in their mid 40s, born in Australia, approximately half were living alone, just under half were taking psychotropic medication and less than one third were receiving counselling. There were no statistically significant differences following comparisons between those who agreed to participate, declined and those who were ineligible, indicating that these groups were comparable based on their demographic characteristics (e.g. age, gender, CALD status).

1.5.2 Quantitative Client Outcome Data

At assessment and follow-up, almost two thirds of participants reported depression and anxiety symptoms above the moderate severity cut-off, and almost one half reported stress symptoms above the moderate severity cut-off as captured by the DASS21 indicating a considerable number of these people experienced psychological distress. On the ASSIST scale over two thirds of participants reported tobacco use above a moderate level of risk, less than one quarter disclosed alcohol use above a moderate level of risk and almost one third of participants stated that they used cannabis above a moderate level of risk indicating substantial numbers of people in this sample using substances at moderate risk levels. On the HONOS scale only a small number of participants were rated at assessment and follow-up as having behavioural problems above the moderate severity cut-off. Approximately one third of people were rated above a moderate level of problem severity on the impairment and

3

symptomatic subscales at assessment with these numbers reduced to just below one fifth at follow-up. Just over two thirds of people were rated above the moderate level of problem severity at assessment on the social problems subscale with these numbers reducing to just above one third at follow-up. These data indicate most of these clients demonstrated functional difficulties in the social problems domain. Participants’ mean scores on all four quality of life domains are considerably lower than Australian population norms reported in the Australian WHOQOL manual. Mean scores on the physical health and psychological health domains are almost two standard deviations lower, and mean scores on the social relationships and environment domains are just over one standard deviation lower than Australian population normative data.

Assessment and follow-up data for clients scoring above the moderate symptom severity on the DASS21 subscales, ASSIST subscales and HONOS subscales were compared. Significant differences were found on the HONOS impairment and social problems subscales indicating improvement at follow-up. Changes in these scores cannot be attributed to the Mental Health Drug and Alcohol CNC role due to the absence of a control group. There were no significant differences on the remaining HONOS subscales or on the DASS21 or ASSIST subscales indicating no change. Mean scores were also compared on the four WHOQOL bref subscales, however no significant differences resulted.

1.5.3 Qualitative Client Outcome Data (Interviews)

To supplement the quantitative evaluation, semi-structured interviews were undertaken with a random sample of 14 clients. These interviews were audio recorded and transcribed for analysis. A thematic analysis of each transcript resulted in the following four themes.

1. Effective mental health care

All fourteen client interviewees considered that the Mental Health Drug and Alcohol Clinical Nurse Consultant role provided effective and empathic mental health care. Interviewees explained that the role provided a vital and valuable health service which was non-judgemental, reliable and responsive to their mental health needs.

2. Enhanced support

Client participants commented on enhanced and valuable support following assessment and care provided by the Mental Health Drug and Alcohol CNC. They reported relief from feelings of isolation, and explained that talking with a caring mental health professional relieved their sense of burden. Participants commented on the value of being able to talk about their psychological health during the assessment process in order to identify how they were feeling.

3. Health promoting education

Client participants explained that they found the health promoting education provided by the Mental Health Drug and Alcohol CNC helpful in relation to their psychological health, drug and alcohol use and mental health symptoms. They considered that the nurse was knowledgeable about mental health, took time to explain, and that the education was reassuring and helped them to cope.

4. Limitations and improvements to the role

All 14 participants reported that there were no significant limitations to the Mental Health Drug and Alcohol role and several people requested:

• Information regarding availability, services offered and how to access the role in future

• Supportive counselling

4

1.5.4 Survey Data (Clients)

The high response rate of 60% to the client survey suggests that this client group were interested and committed participants in the project. Importantly 20 of 25 respondents were satisfied with the Mental Health Drug and Alcohol CNC role with four people endorsing ‘mildly satisfied’ and one person ‘neutral/unsure’. Over 70% of respondents were satisfied: that the Mental Health Drug and Alcohol CNC role was timely; with the questions asked during assessment; that the nurse listened and was understanding, competent and knowledgeable; and that their opinions and choices were respected.

Interestingly, respondents’ endorsement of the ‘satisfied’ response to the items regarding the amount of help received, dealing more effectively with mental health problems, care options, referral options and information received ranges between 44% and 68% with most of the remaining respondents reporting being ‘mildly satisfied’. The numbers of people reporting being satisfied with these areas of the service are lower than those regarding overall satisfaction with the service, timeliness, questions asked, being listened to, the nurse’s competency and that their opinions and choices were respected. This suggests that respondents were well satisfied with the nurse’s interpersonal skills and assessment, and that although most people were at least mildly satisfied, they were not as satisfied in regard to interventions more directly related to psychological symptom management such as care and referral options.

1.5.5 Qualitative Data (Focus Group with RDNS Nurses and Social Workers)

The focus group interview with RDNS staff resulted in the following five themes:

1. Mental health drug and alcohol problems for clients

2. Client care before commencement of the Mental Health Drug and Alcohol CNC role

3. Effectiveness of the Mental Health Drug and Alcohol CNC role

4. Effective collaboration

5. Limitations and improvements to the Mental Health Drug and Alcohol CNC role

Participants’ comments regarding mental health and drug and alcohol difficulties for RDNS clients living with HIV/AIDS highlights their social, behavioural and financial difficulties and how these interfere with their ability to adhere with or commence anti-retroviral medication. Importantly, findings from the focus group identified that the Mental Health Drug and Alcohol CNC role was effective for clients. Participants described this in terms of effective community based mental health drug and alcohol care including: assessment in the community, care management and behaviour management plans focused on keeping the person in the community, advocacy, health promotion, medication management, and prevention of poor mental health and crises. They noted that the role was highly accessible as demonstrated in the highly successful outreach service provided at the Positive Living Centre.

Focus group findings also emphasise that the Mental Health Drug and Alcohol CNC role was collaborative and worked within the nursing team and with the social workers in care provision thereby being an accessible resource and educating RDNS generalist nurses thereby building the capacity of RDNS clinicians to provide better holistic care to clients.

Participants considered that the role as trialled was an underestimation of its true potential due to the developmental nature of the role over the 12 month trial and data collection requirements inhibiting time available to undertake further education. They considered that

5

the role should be refined to promote benefits to the clients and undertake additional education for RDNS staff.

1.5.6 Phone Interview Data (External Service Providers)

Phone interviews with seven external providers resulted in the following four themes:

1. The Mental Health Drug and Alcohol CNC role added value to the community team

2. Effective collaboration with external service providers

3. Improved mental health and drug and alcohol care for clients


The phone interview data emphasise that the Mental Health Drug and Alcohol CNC role added value to and strengthened the community team, collaborated effectively with external service providers, and helped reduce admissions and referrals by RDNS to the acute sector for mental health assessments. Service providers noted that they were able to work together with the Mental Health Drug and Alcohol CNC to provide improved care management to their clients based on focused mental health assessment undertaken in the community rather than in the acute setting. Findings indicate that the Mental Health Drug and Alcohol CNC role provided effective consultation and liaison to these people and worked in partnership with them. These findings further support the important community focus of this role which was highly accessible, available and collaborative.

1.6 Discussion and Conclusion There is a clear need for RDNS clients living with HIV/AIDS to receive focused mental health and drug and alcohol care. Findings from the client profile and evaluation describe over 60% of these people as having mental health and/or drug and alcohol problems. Additionally, the evaluation findings describe this client group as experiencing considerable psychological distress, problematic use of substances, and a substantially lower quality of life than most Australians indicating that they would benefit from additional mental health support notably continued development of the Mental Health Drug and Alcohol Clinical Nurse Consultant role within the RDNS HIV/AIDS Team.

Importantly, evaluation findings in regard to client outcomes, as appraised from the client satisfaction survey and interview data, suggest that the Mental Health Drug and Alcohol CNC role provided an accessible, available and valuable service. Clients reported that the role provided them with vital mental health support. Additionally, clients reported strong satisfaction with this nursing role.

Findings regarding clients’ psychological distress, drug and alcohol risk, functioning and quality of life, as appraised with the valid and reliable measures collected at assessment and 6-8 week follow up, did not find many significant differences, with exception to the impairment and social problems domains of the HONOS indicating that people had improved in these areas at follow-up. Importantly, these findings did not indicate deterioration in these symptom and behavioural areas. The client assessment and follow-up findings are consistent with client survey data which found that although clients reported satisfaction with the Mental Health Drug and Alcohol CNC role, lower levels of satisfaction were reported for the referral and care options survey items. Several factors may explain these findings. There may have been insufficient time to capture any changes. Additionally, evaluation data described the Mental Health Drug and Alcohol CNC role as focused on community based care: assessment

6

in the home, support, access to services such as acute mental health services, referral, health education, health promotion and prevention of poor mental health and crises. Thus the ‘intervention’ did not directly ‘treat’ symptoms or problematic behaviours, but referred to other providers to do so and the effectiveness of referrals and/or direct mental health interventions by other health practitioners was not part of the current evaluation. These issues require further investigation in future studies.

RDNS nurses and social workers participating in the focus group interview and externally based health providers participating in phone interviews reported highly effective collaboration with the Mental Health Drug and Alcohol CNC role. These findings indicate that the role worked in partnership to enhance assessment and care plans for clients and to provide shared care to affected people, increasing their access to services. In particular, the outreach service at the Positive Living Centre was considered to be a highly valuable component of the role as it enhanced access and availability for clients.

Importantly, evaluation findings suggest that the Mental Health Drug and Alcohol CNC role was a community based nursing role operating within the primary care principles of partnership with clients and other health providers, and the role increased access to mental health services. Particularly for clients who are ‘at risk’ or may be placing others ‘at risk’, access to mental health services and care are critical.

The findings of the current project strongly support the continuation of the Mental Health Drug and Alcohol CNC role as a permanent element of the RDNS HIV team. Evaluation findings further indicate that future government health policy in HIV/AIDS should include additional community-based mental health, drug and alcohol nursing care and support for these highly vulnerable people.

1.7 Recommendations In view of the evaluation findings, the following recommendations are made:

1 That the Mental Health Drug and Alcohol Clinical Nurse Consultant role be established as a permanent element of the RDNS HIV team

The findings of the evaluation and the client profile data indicate that over 60% of RDNS clients living with HIV/AIDS experience co-morbid mental health and/or drug and alcohol problems. Over half of them are living alone and have no carer, which increases their risk of social isolation and further predisposes them to poor mental health. People living with HIV/AIDS are living longer, and are therefore more likely to develop major mental disorders as a direct result of the effects of the virus on the central nervous system, including HIV dementia and bipolar disorder. Furthermore, a significant proportion of clients with HIV also have Hepatitis C co-infection and are undergoing treatment for their Hepatitis C, which can result in severe neuro-psychiatric side-effects. In the future, RDNS is likely to receive increasing numbers of referrals for Hepatitis C treatment and support. Therefore, it is anticipated that the already substantial mental health needs of this client group, will continue to increase. Additionally, RDNS clients living with HIV/AIDS report high levels of psychological distress, substance use difficulties and a quality of life significantly below that of their Australian counterparts. This group of people have complex needs which requires specialist expertise to effectively manage, such as that provided by the Mental Health Drug and Alcohol Clinical Nurse Consultant role. In view of the increased demand for mental health drug and alcohol care for this client group, it is recommended that the Victorian Department of Human Services provide recurrent funding to enable the establishment of the Mental Health Drug and Alcohol Clinical Nurse Consultant role as a permanent element of the RDNS HIV Team.

7

2 That the Mental Health Drug and Alcohol Clinical Nurse Consultant role be further developed and expanded

The Mental Health Drug and Alcohol CNC role was found to be highly congruent with that of the existing team of HIV/AIDS Clinical Nurse Consultants and within RDNS. Evaluation findings indicate that the role effectively supported clients to remain in the community and effectively supported management of their social and mental health crises. Moreover, health professionals within RDNS and external to the agency found the role highly collaborative, accessible and available. Throughout the course of the project, the following improvements to the role were also suggested:

− The outreach service at the Positive Living Centre (PLC) should be continued and these arrangements should be formalised between the Victorian AIDS Council (VAC) and RDNS

− Additional outreach services in other regions within the greater Melbourne metropolitan area should be considered

− Linkages between the Mental Health Drug and Alcohol CNC role and mental health and drug and alcohol services should be further developed

− Improved access to direct mental health interventions for RDNS clients living with HIV/AIDS should be considered, including supportive counselling.

3 That the service delivery components of the Mental Health Drug and Alcohol CNC role be modified

Referrals should continue to be made to the Mental Health Drug and Alcohol CNC via the RDNS HIV/AIDS Clinical Nurse Consultants and this should be expanded to include the HIV Resource Nurses. Where relevant, nurses referring people to the Mental Health Drug and Alcohol CNC should use the RDNS Mental Health Screening and Referral Clinical Pathway, which includes the K10 and Alcohol Use Disorder Identification Test (AUDIT) as screening tools, to facilitate their identification of people with actual or potential mental health and/or drug and alcohol problems, and clinical decision making. Referrals from external providers including the Victorian AIDS Council, and the Alfred, Royal Melbourne, St Vincent’s and other public hospitals should be encouraged and continue to develop. Assessment systems including valid and reliable tools used in the evaluation should be modified for future clinical practice to streamline or simplify documentation requirements. It is recommended that future assessment systems include a modified version of the Mental Health Nursing Assessment and the ASSIST.

8

4 That RDNS develops mental health and drug and alcohol activity codes for inclusion in the client database

Ongoing appraisal of mental health and drug and alcohol focused nursing activities as provided by the Mental Health Drug and Alcohol CNC is warranted in order to describe this new service. These data are important information for those funding RDNS, including government, and in order to monitor future health care needs, and consider improvements to the role. It is recommended that these codes be developed in consultation with the relevant clinicians.

5 That the education components of the Mental Health Drug and Alcohol CNC role be expanded

Evaluation findings identified that the education provided by the Mental Health Drug and Alcohol CNC role was highly effective for clients, RDNS nurses and external service providers including volunteer groups at the Victorian AIDS Council. Additionally, evaluation findings indicate that further development of the education component/s of the role are warranted. Findings indicate that additional education in mental health, drug and alcohol and behaviour management could be provided to RDNS staff across the agency. This would build capacity within RDNS to provide ongoing quality care to this client group. Moreover, additional education sessions with this focus could be provided to external services such as volunteer and community support services in HIV/AIDS and integrated into existing education programmes provided by the RDNS HIV Clinical Nurse Consultants.

6 That resources are provided to enable additional investigations to be undertaken to evaluate the impact of the RDNS Mental Health Drug and Alcohol CNC on long-term client outcomes and to appraise the effect of the role on referral systems and care options with external mental health and drug and alcohol services, and with organisations and services catering for clients from culturally and linguistically diverse bacgrounds

Time and resourcing constraints in the current project only allowed short-term follow-up of clients. As measurable changes in psychological functioning and quality of life are unlikely to occur within a short time frame, the provision of additional funding to conduct a 6 to 12 month follow-up of the cohort recruited in this study would be extremely valuable. In addition, the effectiveness of referral systems between the Mental Health Drug and Alcohol CNC and external service providers and care options were not investigated in detail within the current evaluation. Further development, trials and evaluation of referral systems are warranted in this important area of mental health to identify barriers and strategies/systems to enhance access to effective mental health care. The same is required in relation to the identification of barriers and systems to improve access to effective drug and alcohol services. Depression was the most frequently recorded difficulty experienced by these clients and the extensive literature regarding depression indicates that highly effective treatments are available including psychotropic medication and psychotherapy such as cognitive behavioural therapy. Improved access to and uptake of treatments for depression could make a vast difference to the quality of life of RDNS clients living with HIV.

9

2 Introduction Royal District Nursing Service (RDNS) employs approximately 1,000 district nurses across the Melbourne metropolitan region and the Mornington Peninsula. RDNS nurses visit clients in their own homes providing general nursing services including nurse assessment, wound care, aged care, diabetes care and medication assistance; and a range of specialist consultancy nursing services such as the HIV/AIDS Consultancy, Aged Care Consultancy, Cystic Fibrosis Home Support Team, Homeless Persons Program, Diabetes, Haemophilia, Continence, Wound Care, Palliative Care and Stomal Therapy. In the 2006 Calendar year, RDNS nurses provided 37,243 episodes of client care (Royal District Nursing Service, 2007).

RDNS has been providing care to people living with HIV/AIDS since 1985. In 1986, the HIV/AIDS Team of three Clinical Nurse Consultants (CNCs) was established. Given the high prevalence of co-occurring mental health and drug and alcohol problems among RDNS clients living with HIV/AIDS, the trial of a Mental Health Drug and Alcohol Clinical Nurse Consultant as part of the HIV/AIDS Team (Mental Health Drug and Alcohol CNC) is a vital and timely addition to RDNS services.

The Mental Health Drug and Alcohol CNC role was trialled and developed over the 12-month project within the existing RDNS HIV/AIDS Team. The development and refinement of this role was also informed by findings from an evaluation study focused on client outcomes. It was anticipated that multiple benefits for clients would ensue from the trial of the Mental Health Drug and Alcohol CNC role as a result of focused assessment and enhanced treatment planning such as: improved social functioning, adherence with medical treatment regimes, and reduced likelihood of hospitalisation/use of emergency services due to relapse and mental health crises. Additional potential benefits were expected to include strengthening of the RDNS HIV/AIDS Team in its capacity to provide optimal care for clients with co-morbid mental health, drug and alcohol problems; and in providing education and support to wider community groups assisting people living with HIV/AIDS including the Victorian AIDS Council Community Support Programme.

2.1 RDNS HIV/AIDS Model of Care In 1986, the RDNS HIV/AIDS model of care was established with the aim of providing the best possible community nursing care to people living with HIV/AIDS. The model thus integrates nursing care with a speciality HIV/AIDS focus within existing generalist nursing care systems at RDNS. The HIV/AIDS model incorporates referral systems, a consultancy nursing service: the RDNS HIV/AIDS Team; and RDNS generalist clinical services. Any person with a diagnosis of HIV/AIDS requiring district nursing is eligible for care within the RDNS HIV/AIDS model.

RDNS accepts referrals from diverse sources including: public hospitals, general practitioners, community based organisations and clients themselves. The well established RDNS Hospital Liaison Service comprises hospital-based liaison nurses located in most public hospitals throughout Melbourne and creates a vital link between public hospitals and RDNS. RDNS liaison nurses identify clients requiring home nursing and facilitate referrals. Importantly, the Liaison Service includes one part-time specific HIV/AIDS nursing role located at the Alfred Hospital.

The RDNS HIV/AIDS Team consists of three Clinical Nurse Consultants specialising in the care of people living with HIV/AIDS. As Clinical Nurse Consultants they also play a key role in supporting RDNS generalist staff providing specialist assessment, care planning, and care coordination for clients.

10

Thirteen objectives guide care provision by the HIV/AIDS Team:

1. To provide care which will enhance the client’s quality of life through each stage of the disease

2. To identify and respect the client’s needs and wishes in regards to all areas of their health care

3. To preserve client confidentiality regarding the client’s health status, management and care

4. To maintain the client’s confidence in provision of care

5. To facilitate client independence and control

6. To provide focused relevant information and education which will assist the client in making informed decisions about care

7. To support and care for other carers

8. To provide high quality nursing care

9. To work closely and cooperatively with all individuals, families, partners, friends and organisations providing care and support

10. To understand the disease process sufficiently to provide an adequate nursing care plan

11. To provide information and to act as a resource for colleagues and the community

12. To provide appropriate education programs both in the classroom and in the clinical setting for all RDNS staff involved in caring for clients infected with HIV

13. To recommend ongoing development of services within the agency in response to changing needs of the community and clients in light of new HIV related knowledge.

(Royal District Nursing Service, 1997; revised 2008)

These objectives guide the central activities undertaken by the HIV/AIDS Team including to:

1. Conduct carer’s workshops for families and carers of clients with HIV Disease.

2. Provide liaison services, support and advice to managers and carers in community based accommodation facilities such as Horizon Place. These activities are in association with the provision of care to residents and families.

3. Provide information, liaison, support and contributions to HIV specific discussion groups including attendance at regular meetings i.e. Peer Support Groups, Positive Women.

4. Facilitate education and training for local government workers re standard precautions and HIV disease.

5. Present information for Victorian AIDS Council Induction and Education Programs.

11

6. Participate in regular one day ‘in-service’ education programs provided by RDNS Helen Macpherson Smith Institute of Community Health for registered nurses, health aides and other staff addressing nursing management of HIV disease. (Royal District Nursing Service, 1997; revised 2008)

In addition to the three Clinical Nurse Consultants (CNCs), since 2005 the HIV/AIDS Team has included two HIV/AIDS Resource Nurses who take a lead role in care provision for clients at the two RDNS Centres with the highest numbers of HIV/AIDS clients: Yarra and Caulfield. Clients at other RDNS Centres receiving care within the HIV/AIDS model are typically cared for by a generalist primary nurse, in consultation and partnership with one of the HIV/AIDS CNCs. The RDNS General Manager, Director of Nursing Southern Metropolitan Regions provides overall organisational coordination for the model and the RDNS Customer Service Centre Manager provides management support for the HIV/AIDS Team of Clinical Nurse Consultants.

The clinical expertise, education and support provided by the HIV/AIDS Team of Clinical Nurse Consultants plays a major role in ensuring the availability of skilled experienced nursing staff working from RDNS centres.

People living with HIV/AIDS receiving RDNS care within the HIV/AIDS model are funded by the Victorian Department of Human Services Blood Borne Virus/Sexually Transmissible Infections (BBV/STI) Program. The Victorian Department of Human Services BBV/STI Program works in partnership with and facilitates contact with/between all HIV affected communities, for example as represented by: the Victorian AIDS Council, Positive Women, Straight Arrows, People Living with HIV/AIDS (Victoria), the Haemophilia Foundation, and major care providers such as the RDNS HIV/AIDS Team.

2.2 The Need for the HIV/AIDS Mental Health and Drug and Alcohol Clinical Nurse Consultant Role

People living with HIV/AIDS frequently require district nursing care. In Melbourne and the Mornington Peninsula, RDNS is the preferred provider of district nursing care for clients with HIV/AIDS due to the specialist and expert focus of the RDNS HIV/AIDS Team and its integration within the broader organisation. RDNS facilitates and maximises effective community based health care for people living with HIV/AIDS who may otherwise be more reliant on residential nursing care in order to meet their health needs. Residential care is not only more cost ineffective to those funding health care, such as the Victorian Department of Human Services, it is typically not the preferred option of people living with chronic and debilitating health problems, including people living with HIV/AIDS.

It is common for RDNS clients with HIV/AIDS to experience co-occurring mental health and/or drug and alcohol problems leading to multiple challenging and complex health needs and increasing the burden on acute care services when health crises arise. Although the RDNS HIV/AIDS Team Clinical Nurse Consultants are expert in nursing care provision for people living with HIV/AIDS, they do not necessarily have qualifications in mental health and/or drug and alcohol nursing. Additionally, most RDNS nurses are generalist registered nurses with limited experience in providing mental health and drug and alcohol care such as focused assessment and care plan formulation. Therefore, a Clinical Nurse Consultant with the appropriate educational preparation and experience in mental health and drug and alcohol nursing was an important addition to the RDNS HIV/AIDS Team in order to provide a direct clinical care service to clients and to liaise closely with RDNS nurses to support them in care provision.

12

The RDNS HIV/AIDS Team cares for a disproportionate number of people with mental health problems and/or drug and alcohol problems, cognitive impairment, or combinations thereof concomitant with their primary diagnosis of HIV/AIDS (dual diagnoses). Furthermore, many RDNS clients living with HIV/AIDS are from marginalised communities.

According to an analysis of documentation collected over 12 months between 2004-2005 from the RDNS HIV/AIDS Team:

• Fifty-four percent of RDNS HIV/AIDS Program clients experienced some form of mental illness or mental health problem (including anxiety, depression, hypomanic states, suicidal ideation, bipolar disorder, psychosis)

• Thirty-eight percent had drug and alcohol problems

• Over 35% had cognitive and/or mental impairment (such as dementia, memory loss)

• Approximately 40% had Hepatitis B and/or Hepatitis C co–infection (this figure is most likely an underestimation as many clients do not disclose their Hepatitis B and/or C status due to confidentiality concerns)

• Approximately 50% of clients required intervention supports from community support programs such as the Victorian AIDS Council

• Approximately 25% of clients came from culturally and linguistically diverse (CALD) backgrounds

Additionally, it is widely acknowledged that substance abuse is the most common co-occurring problem in people with severe mental illness, however; health service provision for this client group has proved challenging due to limited service availability and stigma (Richardson, 2003). This has typically resulted in adverse health outcomes for people experiencing dual diagnoses. These adverse health and social outcomes have been identified as follows:

• Higher rates of relapse, hospitalisation and use of emergency services

• Increased cognitive deficits

• Decreased adherence to treatments

• Increased criminal offences and likelihood of incarceration

• Increased anger/violence

• Increased risk of unemployment

• Homelessness

• Increased risk of suicide and early mortality; and

• Poorer overall functioning (Lindsay & McDermott, 2000).

Importantly, these health and social problems are even further intensified for people living with HIV/AIDS and co-occurring mental health/drug and alcohol problems due to the effects of stigma associated with HIV infection (Cabassi, 1999). Further, there are significant health issues for people living with HIV/AIDS who have co morbid mental health difficulties in terms of adherence with medication regimes. This client group are at substantially greater risk of non adherence due to cognitive difficulties, depression and substance abuse (Tilley & Chambers, 2006). HIV medications must be taken with at least 95% adherence to minimise adaptation of the virus to medication regimes therefore medication management is of particular concern in RDNS clients living with HIV/AIDS (Paterson et al., 2000).

13

2.3 Project Aim To develop, trial and evaluate a Mental Health Drug and Alcohol CNC role for optimal community nursing care of RDNS clients living with HIV/AIDS.

2.4 Project Objectives 1. To develop and trial a Mental Health Drug and Alcohol CNC role within the RDNS

HIV/AIDS Team with a strong foundation in evidence based practice

2. To develop and trial appropriate and relevant systems supporting the role including:

- Internal and external referral systems

- Assessment systems including reliable and valid screening tools

- Intervention systems based on the best available evidence

- Management of health and/or social crises as related to mental health and/or drug and alcohol issues

3. For the Mental Health Drug and Alcohol CNC role to be congruent with the existing RDNS HIV/AIDS Team

4. For the Mental Health Drug and Alcohol CNC role to provide clinical support and education to RDNS field nurses providing care to clients living with HIV/AIDS

5. To provide the Mental Health Drug and Alcohol CNC role for the consideration of RDNS and the Victorian Department of Human Services - to maximise services and outcomes in relation to the mental health and drug and alcohol needs of RDNS clients living with HIV/AIDS through:

- Optimal assessment and screening

- Focused treatment planning

- Enhanced care coordination and care integration within RDNS clinical care services and with relevant external health and social service providers

6. To facilitate optimal and quality mental health, and drug and alcohol oriented district nursing care for RDNS clients living with HIV/AIDS.

2.5 Anticipated Outcomes The project is expected to result in a number of outcomes as follows.

1. For clients and carers:

- The development of more effective care and enhanced health outcomes for RDNS clients living with co-morbid HIV/AIDS and mental health/drug and alcohol problems

- The facilitation of enhanced nurse-client caring and trusting relationships and promotion of collaborative health care

- Improved health outcomes due to enhanced and focused nursing care in relation to health promotion, health maintenance and disease prevention

- Improved advocacy and access to appropriate health services

- Improved care coordination between diverse health services

- Facilitation of community based health care

14

2. For RDNS:

- Improved understanding of complex health needs of people living with concurrent HIV/AIDS and mental health/drug and alcohol issues including: improved identification of and assessment of relevant health issues, improved fit between health needs and nursing care/interventions

- Satisfaction that appropriate services are involved in care provision within a coordinated approach to holistic health care

- Satisfaction that optimal nursing care based in the best available evidence is provided for this highly vulnerable client group

3. For the Victorian Department of Human Services and RDNS:

- A comprehensive report of the project and evaluation findings will be provided at the conclusion of the 12 month project.

15

3 Methods This 12-month project was conducted over five phases and involved the development and trial of a Mental Health Drug and Alcohol CNC role. A mixed methods evaluation, comprising both qualitative and quantitative approaches, was undertaken concurrently with the development and trial of the Mental Health Drug and Alcohol CNC role. The project timeline describing the five phases is presented in Table 3.1.

Table 3-1 Project Timeline

Jan-Feb

Mar Apr-Sept

Oct Nov-Dec

Phase 1 Orientation & Assessment

Orientation of Mental Health Drug and Alcohol CNC Identification & review of current practices Profile of HIV/AIDS program clients Literature review Selection of screening tools

Phase 2 Planning

Development/modification of MH assessment tool Documentation of project protocol and methods Design of all questionnaires and interview guidelines Submission to RDNS Research Ethics Committee (REC) Establish Reference Group Finalise RDNS REC

Phase 3 Implementation & Evaluation

Commence trial of Mental Health Drug and Alcohol CNC Recruit participants: clients, carers, district nurses &

external service providers Collect client outcome data Collect questionnaire data Undertake interviews/focus groups

Phase 4 Analyses

Analyse all data

Phase 5 Report Findings

Write final report, recommendations & disseminate findings

This section of the protocol describes each of the five phases of the project in regard to the methods.

16

3.1 Phase 1 Orientation & Assessment

3.1.1 Orientation of Mental Health Drug and Alcohol CNC

The development and trial of the Mental Health Drug and Alcohol CNC role commenced from the outset of the project. The first four weeks of the project focused on orientation of the Mental Health Drug and Alcohol CNC to RDNS, including the HIV/AIDS Team, and to the project. During orientation, time was spent meeting with external service providers, for example at Royal Melbourne Hospital and the Alfred Hospital including Fairfield House, in order to introduce key external stakeholders to the developing role and the project.

3.1.2 Identification and Review of Current Practices

Identification and review of current practices occurred concurrently with the orientation of the Mental Health Drug and Alcohol CNC during formal and informal meetings with the Project Team. This process was ongoing over the 12-month project as the mental health, drug and alcohol clinical nurse consultancy role within generalist district nursing is a new and developing area. Relevant findings in regards to current practices with this focus were considered by the Project Team and were infused into care systems developed as part of the Mental Health Drug and Alcohol CNC role.

3.1.3 Profile of HIV/AIDS Program Clients

A profile of the HIV/AIDS program clients who received care from the HIV/AIDS Team over 2006 was formulated using data stored in the RDNS client database. It was anticipated that these data would describe the demographic and case characteristics of clients over the 2006 calendar year who received the HIV/AIDS service. This information was used to describe the client group targeted in the current project, inform project recommendations, and contribute to a more detailed understanding of the health and service needs of this client group.

3.1.4 Literature Review

A comprehensive and focused review of the literature was undertaken during the first phase of the project. The purpose of the literature review was to critically analyse nursing domains of actual and potential relevance to the project. Recommendations based on findings from the literature review were made to the Project Team to facilitate decision making. The scope of the literature review was broad and included:

• Relevant systematic reviews and meta-analyses

• Relevant clinical practice guidelines

• Primary research studies including randomised controlled trials, quasi-experimental designed studies, case control studies

• Qualitative studies

• Relevant non-research literature • Relevant public documents

• Reliability and validation studies pertaining to selected screening and assessment tools

3.1.5 Selection of Screening Tools

Screening tools were selected by the Project Team in consideration of the findings from the literature review and from findings from the review of current practice/s. Additionally,

17

screening tools were selected as based on recommendations from the HIV/AIDS Team clinicians and from the RDNS Department of Research and Development within the Helen Macpherson Smith Institute of Community Health. Key criteria guiding the selection of screening tools included:

• Tool reliability and validity

• Feasibility of tool administration for clients, and for the Mental Health Drug and Alcohol CNC

• Any emergent ethical considerations – to be addressed with the RDNS Research Ethics Committee in accordance with NH&MRC guidelines as per established processes at RDNS.

3.2 Phase 2 Planning

3.2.1 Development/Modification of MH Assessment Tool

In 2005, a project was undertaken at RDNS incorporating the development, trial and evaluation of a Mental Health Clinical Nurse Consultant role. An assessment tool with a mental health focus was developed as part of this project. This tool was reviewed and modified with the Mental Health Drug and Alcohol CNC and HIV/AIDS Team for the current trial.

3.2.2 Documentation of Project Methods

The project methods containing: details regarding the Mental Health Drug and Alcohol CNC role development; and the proposed sample/s, measures, and procedure/s within the evaluation, were submitted to the RDNS Research Ethics Committee in February 2007.

3.2.3 Design of Questionnaires and Interview Guidelines

The project evaluation captured the viewpoints of a number of stakeholders including: clients and carers, district nurses, and external service providers. Clients and carers were invited to complete satisfaction surveys and a small number were invited to participate in a face-to-face interview. District nurses were invited to participate in a focus group and a small number of external stakeholders were invited to participate in a brief phone interview. All surveys and interview guidelines were submitted to the RDNS REC with the project methods for approval.

3.2.4 Submission to RDNS Research Ethics Committee (REC)

An application was made to the RDNS REC in accordance with NH&MRC guidelines during the Planning phase of the project. No data were collected prior to full approval from the RDNS REC.

3.2.5 Finalise Methods in Relation to RDNS REC Requirements

The project methods, specifically in relation to the evaluation, were finalised in accordance with RDNS REC requirements.

3.3 Phase 3 Implementation & Evaluation The project was managed by a Project Officer employed by the RDNS Helen Macpherson Smith Institute of Community Health in conjunction with the Mental Health Drug and

18

Alcohol CNC and HIV/AIDS Team. It was expected that the Mental Health Drug and Alcohol CNC would comprise both clinical and evaluation activities within the 12-month project. Importantly, the RDNS HIV/AIDS Team, within which the Mental Health Drug and Alcohol CNC role was introduced, was both the focus and the shared owner of this project. In this case, involvement of the HIV/AIDS Team as clinical evaluators created the opportunity for a participatory evaluation approach whereby local knowledge was built through the inclusion of different voices, issues and conditions. This democratic form of knowledge generation was balanced by the other quantitative and qualitative data collection in the project, each “validating” the other. The proposed model thus developed in parallel with the evaluation in consultation with clinicians on the HIV/AIDS Team.

The five data collection systems including; the relevant sample, measures and procedures, are described to follow.

3.3.1 Client Recruitment and Collection of Client Demographic, Case and Outcome Data

Sample

Approximately 100 clients are registered on the HIV/AIDS program at any one time. All current and newly admitted clients were invited to participate in the project. Clients providing written consent underwent screening and possible referral to the Mental Health Drug and Alcohol CNC. It was anticipated that a client sample of 50 people would undergo assessment by the Mental Health Drug and Alcohol CNC over the 6 month period of implementation of the role.

Inclusion Criteria: • Must be currently receiving district nursing care from RDNS HIV/AIDS Team on the

HIV/AIDS program • If cognitively impaired, clients on the HIV/AIDS program must have a carer • Must be aged 18 years or over

Exclusion Criteria: • Cognitively impaired and does not have a carer • In opinion of the nurse, the client is too frail to be invited to participate

All clients meeting the selection criteria were invited by the HIV/AIDS Team or one of the HIV Resource Nurses or a primary nurse to participate.

Cognitive impairment was determined by either a current diagnosis of dementia, or if in the opinion of the recruiting nurse the client was unable to give informed consent. The nurse used the Mini Mental State Exam (MMSE) (Folstein, Folstein, & McHugh, 1975) (Appendix A) to assist in making this decision. Additionally, the recruiting nurses used the Client Cognitive Capacity Checklist (Appendix B) to assist them. The Client Cognitive Capacity Checklist has been adapted from a form developed by the Monash University Centre for Developmental Disability to assess the cognitive capacity of adults with intellectual disability. The guidelines provided by the Office of the Public Advocate for obtaining consent from people with cognitive impairment were followed for RDNS clients assessed to be unable to give informed consent due to cognitive impairment, as described below:

• Where the client was assessed as being unable to give informed consent due to cognitive impairment and the client has a carer, they may participate in the project. This may occur where the carer provides consent on behalf of the client in their role as the person responsible and in accordance with the Guardianship and Administration Act – the law on medical research procedures involving adult patients under a legal incapacity - July 2006.

19

http://www.health.vic.gov.au/legislation/info-paper.doc



The carer was identified by the recruiting nurse, in consultation with the client, and where required, their partner and family. In accordance with the Guardianship and Administration Act – the law on medical research procedures involving adult patients under a legal incapacity - July 2006 and Office of the Public Advocate (2006), the person responsible is a person who meets one or more of the following criteria:

• An agent – appointed by the patient under enduring power of attorney (medical treatment)

• A person – appointed by VCAT to make decisions about the proposed treatment • A guardian – appointed by VCAT to make decisions about the proposed treatment • An enduring guardian – appointed by the patient with health care powers • A person – appointed by the patient in writing to make decisions about medical and

dental treatment including the proposed treatment • The patient’s spouse or domestic partner • The patient’s primary carer, … excluding paid carers or service providers • The patient’s nearest relative over the age of 18.

Where the person with an impairment had a carer who could act as the 'person responsible', however the client declined to participate, they did not participate in the project evaluation. Therefore, to be included, clients with cognitive impairment provided verbal agreement to participate, and their carer, in the role of person responsible, provided written consent on the client’s behalf.

Client Recruitment, Screening and Referral

This Project involved the development, introduction and evaluation of a new element of service to the HIV/AIDS clients in RDNS care. Thus, clients were screened as part of their normal service assessment and if they screened positive for stress/anxiety, they were then offered further assessment by the Mental Health Drug and Alcohol CNC. This was explained as a new service which RDNS was introducing, and as such RDNS wished to use some of their data, and to collect some more information from them, to evaluate the service. In this way, clients who wished to avail themselves of the service but not to provide consent for data usage and collection were not disadvantaged as all clients were able to access the service provided by the Mental Health Drug and Alcohol CNC. However, only those clients providing written consent were included in the formal evaluation. The following ‘recruiting’ process was followed: The invitation to participate involved explaining the project to the client/carer using the Plain Language Statement – Clients (Appendix C), and obtaining written consent from the client/carer using either the Consent Form – Clients (Appendix D) or the Consent Form – ‘on behalf of the client’ (Appendix E). Clients who agreed/consented to participate were screened by the HIV/AIDS Team:

• Clients who were not cognitively impaired completed the K10 (Andrew & Slade, 2001; Kessler et al., 2002), a valid and reliable 10 question client/self report measure of general psychological distress (Appendix F).

If the client met one or more of the referral criteria, a referral form was completed, using the existent RDNS Internal Referral Form, and the client was referred to the Mental Health Drug and Alcohol CNC for assessment. If the client did not meet the referral criteria, the client ceased to be part of the project at this point. Referral Criteria:

• Current mental health and or substance use diagnosis/es

20










• Scores positive on the K10 (a score of 16 or above indicates moderate symptom severity (Andrew & Slade, 2001))

• In the opinion of the nurse, client had actual or potential mental health and/or substance use problems.

Mental Health Drug and Alcohol CNC Assessment

The HIV/AIDS Team CNC or HIV Resource Nurse could undertake an introduction visit/accompanying visit with Mental Health Drug and Alcohol CNC if considered appropriate/as required.

Following referral, the Mental Health Drug and Alcohol CNC undertook an assessment in the client’s home using an RDNS Mental Health Assessment Form developed for use by RDNS Mental Health CNCs only. Additional data were collected from the Mental Health Drug and Alcohol CNC assessment and constituted client data for the purposes of the evaluation:

• A standardized, valid and reliable self-report tool for depression, anxiety and stress: Depression Anxiety Stress Scales 21 (DASS21) (Lovibond & Lovibond, 2004) (Appendix G) – used with client participants with no cognitive impairment

• A standardized, valid and reliable substance use scale – the WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (Henry-Edwards, Humeniuk, Ali, Poznyak, & Montiero, 2003) (Appendix H)

• A standardized, valid and reliable clinician rated tool regarding a client’s mental health problems: the Health of the Nation Outcome Scales (HONOS) (Wing et al., 1998) (Appendix I)

• A standardized, valid and reliable quality of Life scale, the WHOQoL BREF (Murphy, Herrman, Hawthorne, Pinzone, & Evert, 2000) (Appendix J) – used with clients with no cognitive impairment.

These assessment data formed the Mental Health Drug and Alcohol CNC’s clinical assessment and were used as assessment measures within the evaluation.

Mental Health Drug and Alcohol CNC Treatment/Care Plan Changes

The Mental Health Drug and Alcohol CNC initiated treatment/care plan changes as based on their assessment/screening findings and in consultation with the RDNS HIV/AIDS Team CNC/field staff and relevant external providers, including the client’s GP, as was clinically indicated.

Mental Health Drug and Alcohol CNC Review of Clients

The Mental Health Drug and Alcohol CNC reviewed all clients 6-8 weeks following their assessment. Although this represents only a very short-term follow-up of clients, it was not possible to assess client outcomes over a longer period due to time and resourcing limitations. Repeat measures were undertaken during this visit using the same measures as in their initial assessment: DASS21, Substance Use Scale – the ASSIST, HONOS and WHOQoL BREF. Mean scores on the repeat measures were compared to ascertain changes in clients’ symptoms before and after assessment and care interventions by the Mental Health Drug and Alcohol CNC.

3.3.2 Client and Carer Surveys

Sample

All cognitively intact clients who participated in an assessment by the Mental Health Drug and Alcohol CNC were invited by the Mental Health Drug and Alcohol CNC, at their last visit, to be contacted by RDNS for the purposes of evaluating the HIV/AIDS services offered

21

and to complete an Evaluation Survey – Clients. With client consent, their carer was also invited to be contacted by RDNS for the purposes of evaluating the HIV/AIDS services and to complete an Evaluation Survey – Carers. Clients who were cognitively impaired were not invited to be contacted by RDNS to complete the Evaluation Survey – Clients; however, their carer was invited to be contacted by RDNS to complete the Evaluation Survey – Carers. Therefore all carers were invited to be contacted by RDNS to complete an Evaluation Survey – Carers. Clients Inclusion Criteria:

• Participated in an assessment by the Mental Health Drug and Alcohol CNC • Aged 18 years or over

Exclusion Criteria: • Cognitively impaired • In opinion of the nurse, the client was too frail to be invited to participate

Carers Inclusion Criteria:

• Currently caring for a client who received care from RDNS HIV/AIDS Team on HIV/AIDS program and who participated in an assessment by the Mental Health Drug and Alcohol CNC

• Is identified by the client as their carer and is not a formal paid carer or a volunteer • Aged 18 years or over

Exclusion Criterion: • In the opinion of the nurse, the carer is too frail to be invited to participate

Client and Carer Recruitment & Procedure

All clients and carers meeting the selection criteria were asked by the Mental Health Drug and Alcohol CNC at their final visit for their permission to be contacted by RDNS to complete a written survey by questionnaire regarding their satisfaction with the Mental Health Drug and Alcohol CNC role. Where clients were cognitively impaired, they were not invited to be contacted by RDNS to complete a written survey. Written consent was not requested as consent is implied upon receipt of a completed survey. At the final review visit, the Mental Health Drug and Alcohol CNC requested clients’ permission for RDNS to contact them and invite them to complete a Satisfaction Survey – Clients (Appendix K). Implied consent was indicated by the completion and return of the survey. A repeat survey was sent to non-responders by a member of the Project Team via regular mail 2-3 weeks following the initial survey to maximize the response rate. Client and carer surveys were coded with the client’s RDNS Unit Record Number in order to match data and undertake exploratory analyses to investigate the effect of potential influencing factors such as age, gender and diagnoses including mental health and drug and alcohol diagnoses.

3.3.3 Client and Carer Interviews

Sample

At the completion of the trial of the Mental Health Drug and Alcohol CNC in October 2007, a sample of clients who were assessed by the Mental Health Drug and Alcohol CNC were randomly selected and invited to participate in an interview undertaken by a member of the

22

Project Team. With the client’s verbal permission and where the carer had in their role as the person responsible consented to participate in the project on behalf of the client, the carer was invited to participate in an interview on the client’s behalf. It was anticipated that this sample of clients and carers would include up to 15 clients. Clients Inclusion Criteria:

• Participated in an assessment by the Mental Health Drug and Alcohol CNC • Cognitively impaired and has a carer • Aged 18 years or over


Carers Inclusion Criterion:

• Carer in the role of person responsible and who is currently caring for a client who is receiving care from RDNS HIV/AIDS Team on HIV/AIDS program and who participated in an assessment by the Mental Health Drug and Alcohol CNC.

Client and Carer Recruitment & Procedure

All selected clients and carers meeting the selection criteria were invited to participate in a face-to-face interview with a member of the Project Team regarding their viewpoint about the effectiveness of the Mental Health Drug and Alcohol CNC role, specifically in relation to assessment and intervention, in assisting them to improve their health outcomes.

Written consent from/for clients with and without cognitive impairment followed the same procedure as that outlined previously using the Plain Language Statement – Clients (Appendix C), Consent Form – Clients (Appendix D) and Consent Form – ‘on behalf of the client’ (Appendix E).

With client and carer permission, interviews were conducted in the client’s home by a member of the Project Team. The Interview Guidelines – Clients & Carers are presented in Appendix L. All interviews were audio-taped for transcription and de-identified interview data were thematically analysed.

3.3.4 Focus Group Interview

Sample

A purposive sample of RDNS nurses was selected comprising the HIV/AIDS Team, HIV/AIDS Resource Nurses, primary nurses, care managers and a social worker. The focus group took place in October 2007 and participants were invited to discuss their viewpoint in undertaking collaborative practice with the Mental Health Drug and Alcohol CNC role, related client outcomes, limitations and suggested improvements.

Inclusion Criteria: • Currently employed by RDNS, and either; • Collaborated in care provision with the Mental Health Drug and Alcohol CNC, or; • Provided management support to the Mental Health Drug and Alcohol CNC in relation

to care provision

23

It was expected that this sample of nurses would include the three HIV/AIDS CNCs, up to two Grade 2 RDNS primary nurses, up to two RDNS Care Manager Nurses, up to two RDNS Assessment nurses, up to two HIV Resource Nurses, and a social worker.

Recruitment & Procedure

At the commencement of the focus group interview, the facilitator of the focus group (the Project Officer) provided each participant with a Plain Language Statement – Focus Group (Appendix M). Participants were requested to provide their written consent using the Consent Form – Focus Group (Appendix N) prior to the focus group interview. The focus group interview was audio-taped for transcribing. The Interview Guidelines – Focus Group are presented in Appendix O.

3.3.5 Phone Interviews

Sample

Selected external service providers were invited to participate in a brief phone interview with the Project Officer at the conclusion of the trial of the Mental Health Drug and Alcohol CNC in October/November 2007 regarding their satisfaction with care collaboration with the Mental Health Drug and Alcohol CNC role. Inclusion Criteria:

• Employed by a relevant external service provider, and; • Collaborated in care provision with the Mental Health Drug and Alcohol CNC.

It was anticipated that this sample would include up to eight participants representing the spectrum of external service providers with a HIV/AIDS focus. Participants were selected based on recommendations from the HIV/AIDS Team. This sample was expected to include representatives from Royal Melbourne Hospital, the Alfred Hospital, Victorian AIDS Council – Community Support Program, and Positive Living Centre.

Recruitment & Procedure

The HIV/AIDS CNCs and Mental Health Drug and Alcohol CNC invited external providers using the Plain Language Statement – External Providers (Appendix P) and requested their written consent using the Consent Form – External Providers (Appendix Q). Once these processes were completed, a member of the Project Team contacted the participant by phone to arrange a suitable time for the phone interview.

A member of the Project Team then contacted the external service provider at the arranged time to undertake the phone interview. The Interview Guidelines – Phone Interviews is contained in Appendix R. Phone interviews were audio-taped for transcribing and thematic analysis.

3.4 Phase 4 Analyses All quantitative data were analysed with the Statistical Package for the Social Sciences (SPSS) Version 15. Data were analysed as follows:

• Demographic and case data – were entered into a database and descriptive statistics analysed

• Quantitative client outcome data (screening/assessment measures and quality of life measure) – were entered into a database and descriptive statistics analysed. Paired t tests were used to appraise change in continuous variables and McNemar’s Chi-square was used to assess change in categorical variables.

24

• Qualitative client outcome data (interview data) - interviews were audio-taped and transcribed for thematic analysis. All interview data were de-identified.

• Survey data (clients and carers) - demographic and scale data were entered into a database and descriptive statistics analysed. Qualitative data were analysed for themes

• Qualitative data (focus group data) – focus groups were audio-taped and transcribed for thematic analysis. All focus group interviews were de-identified.

• Phone interview data (external health providers) – demographic and scale data were entered into a database and descriptive statistics analysed. Qualitative data were analysed for themes.

3.5 Phase 5 Writing of Final Report The final report including project recommendations was written over the final phase of the project between November and December 2007.

3.6 Ethical Issues There were a number of ethical issues identified in relation to the current project. These issues are presented and discussed to follow.

3.6.1 Recruitment of Clients and Carers

Although it is not expected that client participants were at any adverse risk by participating in an assessment by the Mental Health Drug and Alcohol CNC within the new service project, it was possible that they may experience psychological distress in relation to discussing matters related to their thoughts and feelings as was necessary during assessment by the Mental Health Drug and Alcohol CNC. Therefore, general counselling and referral to counselling services specifically tailored for people living with HIV/AIDS was offered to client participants and their carers by the Mental Health Drug and Alcohol CNC who operated in accordance with their scope of practice as a psychiatric nurse with the educational preparation and significant clinical experience in these specialised care domains. Additionally, the role of the RDNS 24 hour 7 day a week Customer Service Centre was considered as part of the development of the Project in relation to their role as a telephone support service.

Clients and their carers may have felt obliged to participate in the evaluation in order to be of assistance to ‘their’ nurse/s due to quality nurse – client caring relationships. Recruiting nurses (nurses on the HIV/AIDS Team) were provided with education prior to the commencement of the trial and a recruitment protocol. They were directed to advise the client and carer that the client’s/carer’s decision to participate would not be considered a favour or similar to the nurse/s or to RDNS. The client/carer was free to choose to participate and their decision would be respected with no effect on their nursing care.

Given the poor health of HIV/AIDS clients who require assistance from the RDNS HIV/AIDS services, it was expected that a number of HIV/AIDS clients would be frail. Therefore, the exclusion criterion “Too frail to participate” was stipulated if, in the opinion of the nurse recruiter, the client was too unwell to be invited to participate.

Clients who were cognitively impaired and did not have a carer who could act as the ‘person responsible’ were excluded from participation in the evaluation as it was not possible to obtain their informed written consent. Cognitive impairment was ascertained by the recruiting nurse using the MMSE to assist them in making this decision and using the Cognitive Capacity Checklist. Clients with a current diagnosis of HIV dementia were excluded where

25

no carer was available. Recruiting nurses were all Registered Nurses on the HIV/AIDS Team with substantial experience in HIV/AIDS nursing. It was therefore expected that these health professionals would have the required expertise to make these assessments.

The recruiting nurses were directed at the pre trial education session to use a procedure developed to maximise opportunities for the client to reflect on participation or not in the project and to do so with a carer if they had one. Therefore, recruiting nurses:

1. Introduced the evaluation project to the clients using the Plain Language Statement – Clients

2. If the client/carer was considering participation, then a second visit was scheduled 3. The client/carer was encouraged by the recruiting nurse to read over the Plain

Language Statement – Clients and/or discuss the evaluation project with a carer/significant other

4. Written consent using the Consent Form – Client/Consent Form – ‘on behalf of the client’ was signed by the client/carer during the second visit.

During invitation and recruitment of potential/actual client participants, the recruiting nurse emphasised to the clients, and where relevant their carer, that participation was voluntary and that they were free to choose to participate or to decline the invitation. Recruiting nurses further emphasised that the client/carer’s decision to participate was not a favour to the nurse/s providing care to them and their decision to participate or not would not affect their care in any way.

3.6.2 Social, Cultural, Linguistic, ‘Other’ Sensitivities of Client Group

Many of the clients who were the focus of this evaluation project have participated in past projects. Therefore, this client group may consider themselves to be ‘over-studied’. The RDNS HIV/AIDS Team Clinical Nurse Consultants, who are represented on the Project Team, have extensive clinical experience in providing nursing care to this client group and specialised knowledge, and were consulted regarding this question.

Where potential client and carer participants were from a culturally and linguistically diverse background (CALD), and they met the selection criteria, they were invited to participate. For CALD clients and carers who did not speak or understand verbal and written English sufficiently to give informed consent to participate, recruiting nurses followed standard RDNS policies and procedures and arranged a joint visit to the client’s home with an interpreter. The recruiting nurse then informed and explained the Project to the client and carer using the recruitment procedure outlined previously with the assistance of the interpreter prior to obtaining the client’s/carer’s written consent.

3.6.3 Recruitment of Community Nurses

During recruitment of community nurses and social workers to participate in the focus group, the clinicians were verbally informed by the focus group facilitator (a member of the Project Team) that they were free to choose to participate in the evaluation project and that they had the right to refuse without their employment being affected in any way. A statement to this effect is included in the Plain Language Statement – Focus Group.

3.6.4 Recruitment of External Service Providers

During recruitment of external service providers to participate in the phone interviews, the nurse recruiters verbally informed potential participants, as emphasised during the pre trial education, that they were free to choose to participate in the evaluation project and they had

26

the right to refuse without their working relationship with RDNS being affected in any way. A statement to this effect is included in the Plain Language Statement – External Service Providers.

3.6.5 Privacy & Confidentiality

• Access to all client data captured as part of the evaluation was undertaken according to the RDNS Privacy Policy and in accordance with the Privacy Act 1988.

All client data were identified using the client’s RDNS Unit Record Number. This was for the purpose of matching clients’ pre and post measures, demographic and case data, satisfaction data and interview data in order to obtain a more accurate profile of client participants in each data collection system and across data collection systems. Additionally, each client was given a project identifying number which was contained on electronic databases and hardcopy data. All data reported in the final report and in any subsequent publications were de-identified. All hardcopy data were stored in locked cabinets at the RDNS Helen Macpherson Smith Institute of Community Health. All electronic data were stored on computers at the RDNS Helen Macpherson Smith Institute of Community Health. All participants’ names, addresses or any other identifying information were kept separately from databases. All evaluation data were kept and securely stored separately from participants’ names and addresses, and audiotapes were kept separately from transcripts. No identifying information was recorded onto audiotapes.

The only people with access to these data were the Project Team. There were two exceptions: the person transcribing the focus group and interview data – this person was required to sign a confidentiality agreement (Appendix S); additionally, those participating in the focus group heard data provided by others in the focus group. During the focus group, the interviewer directed participants regarding confidentiality and the expectation that confidentiality was to be maintained during the focus group and upon its completion.

Upon completion of the study, all audio-taped recordings, and hardcopy data including interview transcripts, will be stored in archives at Helen Macpherson Smith Institute of Community Health for no less than five years. After five years, these data will be destroyed by a process of confidential shredding and erasing.

27

4 Profile of RDNS Clients Living with HIV/AIDS At the outset of the development and evaluation of the Mental Health Drug and Alcohol CNC role a profile of RDNS clients living with HIV/AIDS was undertaken. This client profile aimed to describe RDNS clients with HIV/AIDS over the 2006 calendar year. As improved care of clients living with HIV/AIDS and co-morbid mental health and drug and alcohol problems was the overall aim of the development and evaluation of the Mental Health Drug and Alcohol Clinical Nurse Consultant role for clients living with HIV/AIDS, the profile of client episodes was expected to assist in describing and defining the target group. It was anticipated that this profile would be of further assistance in matching up strategies and guidelines within the development of this role to meet the needs of clients living with HIV/AIDS and co-morbid mental health drug and alcohol problems.

4.1 Method All demographic and service delivery data for RDNS clients on the HIV/AIDS program for the 2006 calendar year were retrieved from the RDNS client database. RDNS is a provider of general district nursing services, therefore, physical health diagnoses are typically recorded as primary diagnoses and mental health, drug and alcohol diagnoses represent secondary diagnoses. Within the RDNS client database, mental health drug and alcohol disorders are recorded using the ICD-9 classificatory system2. In this system, mental health conditions, including drug and alcohol conditions, are categorised within the range of codes between 290 and 319 and represent:

• Depressive disorders

• Anxiety disorders

• Drug and alcohol dependency and abuse disorders

• Dementias

• Schizophrenia and psychotic disorders

• Bipolar disorders

• Personality disorders

• Mental retardation

• Mental disorders related to a medical condition

• Other mental disorders

Within the ICD-9 classificatory system, some types of dementia are excluded, for example Alzheimer’s dementia.

Additionally, client demographic and service provision data were retrieved. These data included: gender, age, country of origin, carer availability, living arrangements, treating centre, source of referral, staff type and visit activity.

2 The provision of an ICD-9 diagnosis is dependent on the GP or generalist RDNS nurse, neither of whom may be in a position to do this with any confidence given their lack of specific mental health experience or training.

28

4.2 Results

4.2.1 Demographic Characteristics

Of all client admission episodes on the RDNS client database for the 2006 calendar year, 141 were recorded for people living with HIV/AIDS, all of whom were funded under the HIV/AIDS program. On average, these clients were aged 46 years (sd=12.3, range=22-84) and 79.4% were male. Figure 4.1 displays the age distribution of clients living with HIV/AIDS.

80 - 89 years

70 - 79 years

60 - 69 years

50 - 59 years

40 - 49 years

30 - 39 years

20 - 29 years

Age Group

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Perc

ent

Figure 4-1 Age Distribution of Clients Living with HIV/AIDS (N=141)

Over three quarters of clients living with HIV/AIDS were born in Australia, and greater than 2% of clients were born in England, New Zealand, Vietnam, Cambodia and Italy. Country of origin data are presented in Table 4.1. Of the total number of clients, 5 % were Indigenous Australians.

29

Table 4-1 Country of Origin for Clients Living with HIV/AIDS (N=141)

Country of Origin N %

Australia 101 71.6

England 4 2.8

New Zealand 4 2.8

Vietnam 4 2.8

Cambodia 3 2.1

Italy 3 2.1

Other* 21 14.9

Not Recorded 1 0.7

*Includes n=1 for various countries

Carer Availability, Living Arrangements and ‘At Risk’ Register

Carer availability data are presented in Table 4.2. Over one quarter of clients were recorded as not requiring a carer and just under one third lived alone with no carer. Carers were not required or clients were living alone with no residential carer for almost 65% of client episodes recorded for the 2006 calendar year.

Table 4-2 Carer Availability for Clients Living with HIV/AIDS (N=141)

Carer Availability N %

Carer not needed 52 36.9

Lives alone has no carer 38 27.0

Lives with another has resident carer

18 12.8

Lives with another has no carer

13 9.2

Lives in supported accommodation

8 5.7

Lives alone has a carer 5 3.5

Lives in a mutually dependent situation

1 0.7

Not Recorded 6 4.3

Living arrangements for clients living with HIV/AIDS are displayed in Table 4.3. Of the HIV/AIDS client episodes, almost one half lived alone and just under one third lived with family.

30

Table 4-3 Living Arrangements for Clients Living with HIV/AIDS (N=141)

Living Arrangements N %

Lives alone 67 47.5

Lives with family 41 29.1

Lives with others 13 9.2

Lives in special purpose accommodation

8 5.7

Not Recorded 12 8.5

Of all recorded client episodes, 9% were recorded on the RDNS ‘At Risk’ register. Clients are listed on this register when clinical staff assess that a client is ‘at risk’ of harm or neglect, or if their behaviour can pose a risk for staff or others. An accompanying process to assist ‘at risk’ clients typically involves urgent case meetings with RDNS social workers and nurses in addition to relevant members of the client’s health care team, such as their GP and mental health practitioners, where a plan of care addressing risk issues is formulated. This can include referral on to government departments such as Child Protection and the Department of Human Service Partner Notification Officers.

4.2.2 Treating Centre

The frequency of episodes involving clients living with HIV/AIDS for RDNS centres is presented in Table 4.4. Notably, most HIV/AIDS client episodes were recorded for Caulfield, Yarra and Altona centres, the three centres where RDNS HIV/AIDS Clinical Nurse Consultants are based. Additionally, Caulfield and Yarra are the centres where RDNS HIV/AIDS Resource Nurses are based in order to provide an extra level of specialised nursing support.

4.2.3 Source of Referral for RDNS Clients living with HIV/AIDS

Over two thirds of clients living with HIV/AIDS were referred to RDNS from acute care public hospitals. Over one tenth of clients were referred by their medical practitioner and smaller numbers of clients referred themselves. These data indicate that RDNS liaison services, who facilitate all referrals from acute care public hospitals to RDNS, are central to ensuring appropriate referrals for people living with HIV/AIDS from the acute care setting to RDNS. Table 4.5 illustrates these data.

31

Table 4-4 Frequency of Episodes Involving Clients Living with HIV/AIDS by RDNS Centre (N=141)

RDNS Treating Centre N %

Caulfield 37 26.2

Yarra 30 21.3

Altona 15 10.6

Liaison 10 7.1

Essendon 9 6.4

Moreland 7 5.0

Heidelberg 6 4.3

Box Hill 4 2.8

Camberwell 4 2.8

Diamond Valley 3 2.1

Homeless Persons Program 3 2.1

Sunshine 3 2.1

Frankston 2 1.4

Knox 2 1.4

Berwick 1 0.7

Cranbourne 1 0.7

Gisborne 1 0.7

Moorabbin 1 0.7

Rosebud 1 0.7

Springvale 1 0.7

Table 4-5 Source of Referral to RDNS for Episodes Involving Clients Living with HIV/AIDS (N=141)

Source of Referral N %

Acute Hospital – Public 111 78.7

Medical Practitioner 15 10.6

Self 8 5.7

Community Service Provider 4 2.8

Family, Friend, Neighbour 2 1.4

Extended Care Rehabilitation 1 0.7

32

4.2.4 Mental Disorder and Drug and Alcohol Disorder Diagnoses

Of all 141 client episodes recorded for the 2006 calendar year, 89 (63.1%) had a mental disorder and/or drug and alcohol disorder recorded. Table 4.6 presents the ICD-9 mental disorder and drug and alcohol disorder diagnoses for client episodes involving clients living with HIV/AIDS. Over half of all client episodes where a diagnosis of a mental health and or drug and alcohol disorder were recorded involved caring for a client with HIV/AIDS and depression and/or anxiety. Over one tenth of client episodes were also recorded for clients with non dependent drug abuse.

Of all 89 HIV/AIDS client episodes where a mental health disorder and/or drug and alcohol disorder were recorded, clients were aged on average 44.3 years (sd=11.6) and 64 (71.9%) were male. Comparison of the proportion of client episodes involving males and females with and without recorded mental disorders and/or drug and alcohol disorders was significantly different (Phi Coefficient=0.25, p<0.05). This finding is consistent with the greater proportion of male clients with HIV/AIDS.

Table 4.7 displays the demographic characteristics by ICD-9 mental health, drug and alcohol disorder diagnoses. These data indicate that for most HIV/AIDS client episodes with a mental disorder, clients were middle aged males.

Carer availability by the top five mental disorders and/or drug and alcohol disorders data are presented in Table 4.8. In over one quarter of all episodes, the client lived alone without a carer and for almost one half of client episodes where depression, or non dependent drug abuse or affective psychoses was recorded, carer availability was coded as ‘not needed’. Approximately one third of client episodes recorded ‘carer not needed’ for those visits where clients had anxiety or non-psychotic mental disorder due to brain damage.

Living arrangements by the top five mental disorders and/or drug and alcohol disorders data are presented in Table 4.9. Notably, almost half of the client episodes where clients had depression or anxiety, or non dependent drug abuse involved clients who lived on their own. Additionally, more than half of the client episodes where clients had affective psychoses or non-psychotic mental disorder due to brain damage involved clients living alone.

33

34

Table 4-6 Mental Disorder and Drug and Alcohol Disorder Diagnoses for Client Care Episodes Involving Clients Living with HIV/AIDS and a Mental Disorder/s (n=89)*

ICD-9 Diagnosis- n % Depression 43 30.5 Anxiety 35 24.8 Non Dependent Drug Abuse 19 13.5 Affective Psychoses 11 7.8 Nonpsychotic Mental Disorder due to Brain Damage 10 7.1 Psychoses 9 6.4 Personality Disorder 7 5.0 Bipolar Disorder 6 4.3 Schizophrenia 4 2.8 Drug Dependence 2 1.4 Other Nonorganic Psychoses 2 1.4 Mental Retardation 1 0.7 Acute Reaction to Stress 1 0.7 Adjustment Reaction 1 0.7 Other Organic Psychotic Conditions – Chronic 1 0.7

* Clients may have more than one diagnosis

Table 4-7 Demographic Characteristics by Mental Disorder and Drug and Alcohol Disorder Diagnoses (N=141)

ICD-9 Diagnosis- n Mean Age % Male Depression 43 42.4 (10.2) 79.1 Anxiety 35 43.1 (10.6) 71.4 Non Dependent Drug Abuse 19 40.0 (9.0) 84.5 Affective Psychoses 11 46.6 (5.5) 81.8 Nonpsychotic Mental Disorder due to Brain Damage

10 53.7 (15.7) 80.0

Psychoses 9 41.0 (6.6) 66.7 Personality Disorder 7 39.9 (7.2) 42.9 Bipolar Disorder 6 48.1 (4.8) 83.3 Schizophrenia 4 36.3 (2.7) 50.0 Drug Dependence 2 44.7 (3.3) 50.0 Other Nonorganic Psychoses 2 47.8 (5.4) 0.0 Mental Retardation 1 56.7 100.0 Acute Reaction to Stress 1 36.3 0.0 Adjustment Reaction 1 83.6 0.0 Other Organic Psychotic Conditions – Chronic

1 43.8 100.0

* Figures in parentheses are standard deviations

Table 4-8 Carer Availability by the Top Five Mental Disorder and Drug and Alcohol Disorder Diagnoses (N=141)

Carer Availability

Carer not needed

Lives alone has no carer

Lives with another has resident carer

Lives with another has no carer


Lives alone has a carer

Lives in a mutually dependent situation

Not Recorded

ICD-9 Diagnosis n % n % N % n % n % n % n % n %

Depression

n=43

22 51.2 11 25.6 0 0.0 5 11.6 4 9.3 0 0.0 0 0.0 1 2.3

Anxiety

n=35

13 37.1 8 22.9 2 5.7 5 14.3 2 5.7 2 5.7 0 0.0 3 8.6

Non Dependent Drug Abuse

n=19

9 47.4 6 31.6 0 0.0 2 10.5 1 5.3 1 5.3 0 0.0 0 0.0

Affective Psychoses

n=11

5 45.5 4 36.4 1 9.1 1 9.1 0 0.0 0 0.0 0 0.0 0 0.0

Nonpsychotic Mental Disorder due to Brain Damage

n=10

3 30.0 3 30.0 0 0.0 0 0.0 4 40.0 0 0.0 0 0.0 0 0.0

35

Table 4-9 Living Arrangements by the Top Five Mental Disorder and Drug and Alcohol Disorder Diagnoses (N=141)

Living Arrangements

Lives alone Lives with family Lives with others Lives in special purpose accommodation

Not Recorded

ICD-9 Diagnosis n % n % n % n % n %

Depression

n=43

21 48.8 11 25.6 6 14.0 4 9.3 1 2.3

Anxiety

n=35

14 40.0 11 31.4 6 17.1 2 5.7 2 5.7

Non Dependent Drug Abuse

n=19

9 47.4 4 21.1 4 21.1 0 0.0 2 10.6

Affective Psychoses

n=11

6 54.5 1 9.1 2 18.2 1 9.1 1 9.1

Nonpsychotic Mental Disorder due to Brain Damage

n=10

5 50.0 1 10.0 0 0.0 4 40.0 0 0.0

36

4.2.5 Visit Information Over the 2006 calendar year, RDNS staff made 13,703 client related contacts regarding clients living with HIV/AIDS. Of these contacts including visits, the median duration was 0.33 hours (range=0-7.0). Table 4.10 presents RDNS staff type by visit frequency for clients living with HIV/AIDS. Over one third of client visits were undertaken by RDNS generic nurses and over one third of visits to clients living with HIV/AIDS were undertaken by the three HIV/AIDS CNCs.

Table 4-10 RDNS Staff Type by Frequency of Client Care Visits Involving Clients Living with HIV/AIDS (n=13,703)

Staff Type n % Field Staff 5467 39.9 HIV/AIDS CNC 4790 35.0 Liaison 1165 8.5 Social Worker 418 3.1 Health Aid 191 1.4 Homeless Persons Program 103 0.8 Mental Health Drug and Alcohol CNC

58 0.4

Occupational Therapist 56 0.4 Physiotherapist 21 0.2 Other 1434 10.3

Table 4.11 displays RDNS visit activity by the frequency of client home visits for clients living with HIV/AIDS over the 2006 calendar year. Over two thirds of home visits involved health monitoring by the nurses; over half of all client home visits involved counselling and support, and over one third of these visits involved medication administration activities.

37

Table 4-11 RDNS Visit Activity by Frequency of Client Care Visits Involving Clients Living with HIV/AIDS (n=12,365)

Visit Activity n %* Health Monitoring 3425 70.7 Counselling and Support 2563 52.9 Medication Administration and Preparation

1898 39.2

Assessment – Other 1324 27.3 Client Care Coordination Collaboration

1116 23.0

Medication Administration - Other Injection

404 8.3

Technical Care - Wound 393 8.1 Education – Other 378 7.8 Technical Care - Other 184 3.8 General Nursing Care 132 2.7 Other 548 11.5

* Up to five visit activities may be recorded per client visit

4.3 Discussion Findings from this profile of RDNS clients with HIV/AIDS over the 2006 calendar year indicate that mental health and drug and alcohol disorders are highly prevalent among this client group. A significant number (63.1%) of RDNS clients living with HIV/AIDS had a mental disorder and/or drug and alcohol disorder recorded. This is over three times greater than that found for all RDNS clients (18.8%) in the client profile undertaken as part of the RDNS Model of Mental Health Care project (Nunn & Allen, 2006). The most frequently occurring diagnoses were depression, anxiety and non dependent drug abuse.

The strong relationship between HIV/AIDS and depression, anxiety and substance use is a consistent finding in the literature (Richardson, 2003) and is related to the burden of living with a chronic and debilitating disease.

Demographic data suggest that most in this client group are in their early 40s, are male, and were born in Australia.However, this is also a very diverse and complex client group with a significant number of clients being born in countries other than Australia and many having Aboriginal or Torres Strait Islander backgrounds. In addition, there is a disproportionate number of female clients receiving care from the RDNS HIV/AIDS Team. Carer availability and living arrangements data indicate that many of these clients live alone with no carer, or do not require a carer, with almost half of all clients living with HIV/AIDS living alone. Similarly, living arrangement and carer availability data for those clients living with HIV/AIDS with co-morbid depression, anxiety and/or non dependent drug abuse reveals that approximately one half of these clients live alone and approximately one quarter of clients living alone did not have a carer.

The demographic, carer availability and living arrangement data suggest that those RDNS clients living with HIV/AIDS with a mental health problem vary from RDNS clients with a mental disorder, as captured in the RDNS profile of all clients undertaken in 2005, in that clients living with HIV/AIDS and a mental health problem/s are younger, typically male, with a higher proportion living alone or living alone with no carer.

38

In relation to the client visit data, over half of all client episodes involving clients living with HIV/AIDS occurred in the South, East and West of Melbourne’s inner city areas. As noted, these areas are covered by the three centres where the Clinical Nurse Consultant and Resource Nurse roles are based indicating that nursing resources are well matched with client demand. Over three quarters of referrals result from acute public hospitals reflecting the frequent utilisation of acute care and community nursing by these clients in managing their health issues.

The visit activity data indicate that health monitoring, counselling and medication administration/preparation are the three most frequent nursing care activities undertaken for RDNS clients living with HIV/AIDS. In past literature, a strong relationship has been found between the coexistence of mental health drug and alcohol problems and HIV/AIDS and increased difficulty in adhering to the complex HIV/AIDS treatment regimes, such as medication regimes, further compromising the health of affected people (Tilley & Chambers, 2006) indicating that medication management may be challenging for this client group.

Findings from this client profile indicate a number of important considerations in providing optimally focused nursing care for RDNS clients living with HIV/AIDS. RDNS clients living with HIV/AIDS are a vulnerable group of people due to their frail health and social isolation. Clients living with HIV/AIDS with co-occurring mental health and/or drug and alcohol problems are even more vulnerable given their profile of frequently living alone with no carer and the strong association between poor physical and mental health, and social isolation. In view of these findings, effective and specialised nursing care for clients living with HIV/AIDS should:

• Have a strong foundation in social, psychological and medical models of health care

• Incorporate sound knowledge of mental health and drug and alcohol issues specifically for people living with HIV/AIDS

• Incorporate focused assessments, including those in relation to HIV/AIDS, mental health drug and alcohol, risk and adherence with medical treatments, which includes an appraisal of the actual or potential interactions occurring between these complex health problems (mental health, social health and physical health)

• Infuse a specialised mental health drug and alcohol Clinical Nurse Consultant role into the existing RDNS HIV/AIDS model.

39

5 Development of the HIV/AIDS Mental Health and Drug and Alcohol Clinical Nurse Consultant Role

Development of the Mental Health Drug and Alcohol CNC role was the central focus of the project and occurred concurrently with the project evaluation. Prior to the commencement of the Mental Health Drug and Alcohol CNC role, a review of the literature was undertaken to assist in defining the Mental Health Drug and Alcohol CNC role. The Mental Health Drug and Alcohol CNC role was further defined over the course of the project based on ongoing discussion with the HIV/AIDS Team of CNCs including the Mental Health Drug and Alcohol CNC and in consultation with the Project Team established at the outset of the project. Therefore, clinical practice issues, the collective clinical expertise of the HIV/AIDS Team and the literature all contributed to the development of the Mental Health Drug and Alcohol CNC role. The literature review is discussed below and a description and definition of the Mental Health Drug and Alcohol CNC role as was developed during the trial is provided to follow.

5.1 Literature Review Currently, in Australian community nursing contexts with a general nursing focus, mental health and drug and alcohol nursing consultancies are limited. Additionally, few publications address these nursing domains within generalist community nursing contexts suggesting that few if any similar roles exist internationally.

Given the absence of published material in relation to mental health and drug and alcohol nursing roles in generalist community nursing settings, a literature review was undertaken of the consultation liaison psychiatry nursing role which is an advanced practice nursing role typically undertaken in acute care inpatient settings targeting patients presenting with physical health problems who also develop mental health difficulties. The consultation liaison psychiatry nursing role was therefore considered to approximate the mental health component of the mental health drug and alcohol Clinical Nurse Consultant role at RDNS. Additionally, as limited publications addressing drug and alcohol nursing consultancies in generalist health care settings were identified, publications were considered regarding the effectiveness of drug and alcohol nursing roles in any setting.

5.1.1 Definitions of the Consultation Liaison Psychiatry Nursing Role

One empirical study and a number of opinion based papers were identified which described the consultation liaison psychiatry nursing role. In an empirical investigation, a profile of the consultation liaison psychiatry nurse within an Australian hospital network was undertaken including acute inpatient care and an inpatient rehabilitation setting (Sharrock & Happell, 2001). This exploratory study found that the consultation liaison psychiatry nursing role provided a service to: nursing, medicine and allied health; encompassed a range of interventions including: advice and guidance to colleagues regarding patients with co morbid physical health and mental health difficulties, and recommended improved management via case discussion and care plan formulation. The consultation liaison psychiatry nursing role also provided direct patient care including assessment, monitoring of mental health needs, supportive counselling and patient education (Sharrock & Happell, 2001). Importantly, case consultation represented the largest proportion of activities undertaken within this role accounting for 71% of the nurse’s time.

In another publication, these authors consider that the consultation liaison psychiatry nursing role is primarily focused on consultation to general hospital staff in regards to caring for patients presenting for physical health problems who experience co morbid mental health difficulties (Sharrock & Happell, 2000). Accordingly, this role is focused on management strategies for nurses regarding assessment and care planning in particular for patients suffering from depression, anxiety and behaviour disturbance and therefore it varies from the consultation liaison psychiatrist role focused on

40

medical diagnosis and treatment. The consultation liaison psychiatry nursing role is also characterised by consultation to nursing staff, education to the multidisciplinary team, and the provision of direct care to patients such as assessment, crisis intervention (including management of people with self-harming behaviours and suicide attempts), short term psychological interventions e.g. supportive counselling, expertise in psychiatric problems and responses to illnesses including adaptation to chronic illness (Roberts, 1997). Importantly, Roberts emphasises that the role provides the multidisciplinary team with a valuable addition to medical psychiatry due to the focus on mental health nursing incorporating social and psychological frameworks of caring into the nurse-patient therapeutic relationship. Roberts considers that the role should further develop in community nursing care settings and in the care of people living with HIV/AIDS.

Other authors (Minarik & Neese, 2002) consider the consultation liaison psychiatry nursing role as an advanced practice subspecialty of mental health nursing which has developed due to the increasing recognition of the negative effects of mental health difficulties on physical health and recovery from physical illness. Minarik and Neesse emphasise collaboration, consultation and liaison as central components of the role. They describe the presenting problem as patient, staff, system related or combinations thereof. Therefore the assessment involves an assessment of the entire consultation problem (Minarik & Neese). Within the ‘consultation’ domain of the role, the consultation liaison psychiatry nurse may provide direct care to patients or have direct contact with nurses regarding interventions with the patient. According to Minarik and Neese, the ‘liaison’ characteristic of the role is focused on linking the consultation liaison psychiatry nurse with the client and or family, and also on collaboration and partnership building with the health care team for example: education, discharge planning, care planning, team rounds, care conferences, and facilitation of support groups. Another author (Norwood, 1998) isolates these consultation and liaison functions further within the ‘nursing consultation process’ which refers to therapeutic relationships forming a triad of: ‘nurse consultant’-‘consultee’(generalist nurses and health professionals) and ‘client’ (including the client/patient and their family). Similarly to Roberts (1997), Norwood comments on the need for the consultation liaison psychiatry nursing role to subspecialise in community settings with varying client groups including people living with HIV/AIDS.

5.1.2 Investigations of the Effectiveness of the Consultation Liaison Psychiatry Nursing Role

A number of studies were identified in the published literature which appraised the effectiveness of the consultation liaison psychiatry nursing role. Two of these studies appraised role effectiveness on clients. The majority of these studies investigated role effectiveness as reported by nurses and other health professional colleagues.

In one study of the effectiveness of the role on clients in a general hospital in Greece, a convenience sample of 95 general hospital patients who presented with psychological or psychiatric problems during their hospital stay for physical health problems were interviewed (Priami & Plati, 1997). The most prevalent psychiatric diagnoses recorded by a psychiatrist for these people included depression (34.7%), anxiety (32.7%), psychotic syndrome (16.8%) and adjustment reaction (15.8%). Nursing interventions practised within the role included psychological support, active listening, reality testing, patient education and consultation. Priami and Plati interviewed this sample of people prior to discharge and found that 69% believed the interventions undertaken by the consultation liaison psychiatry nurse assisted in relief of their physical symptoms and most of these people considered that the nursing interventions had relieved their psychological symptoms. In another study (Callaghan, Eales, Coats, Bowers, & Bunker, 2002), findings were reported from an evaluation of a mental health liaison service in an accident and emergency department in the UK including mental health nurses, psychiatrists and allied health staff. Callaghan et al interviewed a random sample of 17 clients and found that these people reported valuing the mental health expertise of staff and their suggestions for different ways of dealing with their difficulties, taking the time to talk to them and undertake an assessment, and having access to a psychiatrist.

41

It is of note that few studies were identified which appraised the effectiveness of the consultation liaison psychiatry nursing role on client outcomes such as mental health symptoms or quality of life and no studies were identified which appraised the effectiveness of the community based consultation liaison psychiatry nursing role in care provision to people living with HIV/AIDS. This suggests that a study appraising outcomes for people living with HIV/AIDS would add considerably to the literature and knowledge base regarding clients’ responses to community based consultation liaison psychiatry nursing roles and provide valuable information for clinicians and policy makers supporting implementation of these roles in the care of people living with HIV/AIDS.

Other studies report favourable findings from surveys of health professionals collaborating with consultation liaison psychiatry nurses in acute care inpatient settings. In one of these studies (Brendon & Reet, 2000), findings are reported from a satisfaction survey collected from health professional colleagues of an in patient mental health liaison nursing service. They sent 86 surveys to all doctors and nurses in the accident and emergency, medical and midwifery departments and to psychiatrists. Twenty-nine were returned resulting in a 39% response rate. The most frequently cited reason for referral was assessment of mental state including assessment of self harm. Overall, respondents reported good levels of satisfaction with the speed of response, quality of assessment, outcomes of the service and quality of documentation. Other writers also report highly favourable responses by emergency department staff to the consultation liaison psychiatry nursing role due to assessment expertise, availability of a mental health resource, and mental health education (Wand, 2004; Wand & Happell, 2001). Additionally, health professionals in accident and emergency departments have found the consultation liaison psychiatry nurse role results in an improved standard of care and better patient outcomes (Wand & Happell, 2001). Similarly, other investigators (Sharrock & Happell, 2001, , 2002) surveyed health professionals in a large urban based Australian public hospital regarding satisfaction with care provided by a consultation liaison psychiatry nurse role. Overall, respondents in this study reported high levels of satisfaction that the nurse had met a previously unmet need, was accessible, assisted in continuity of care provision, assisted other health professionals to provide improved management for their patients, and resulted in improved health outcomes for patients. In a later study (Sharrock, Grigg, Happell, Keeble-Devlin, & Jennings, 2006), the addition of a consultation liaison psychiatric nursing position to a large Australian general public hospital was evaluated. This study repeated findings presented in earlier studies (Brendon & Reet, 2000; Wand & Happell, 2001); Brendon & Reet, 2000, Sharrock and Happell, 2001, 2002; Wand & Happell, 2001, 2002; Wand, 2004). They undertook focus groups with staff and found participants considered the role improved access for patients to specialist mental health care and was effective in providing practical care interventions with their patients.

All of these studies (Brendon & Reet, 2000, Sharrock and Happell, 2001, 2002; Sharrock, Grigg, Happell, Keebl-Devlin & Jennings, 2006; Wand & Happell, 2001, 2002; Wand, 2004) focus on acute care in inpatient settings, in particular accident and emergency departments. Therefore it is not known from these studies how effective the consultation liaison psychiatry role would be according to community health professionals.

Only one investigation was identified which appraised the consultation liaison psychiatry role in a community setting. In this study (Harmon, Carr, & Lewin, 2000),a consultation liaison psychiatry nursing model in general practice settings in Australia was evaluated. This study included a convenience sample of 100 patients the majority of whom were referred by GPs. Reasons for referral included advice regarding management, diagnostic assessment, depression, assessment for risk of suicidal behaviour, crisis assessment and intervention, and psychosis. The consultation liaison psychiatry nurses worked in partnership with GPs and provided clinical assessment, consultation and feedback to the GPs, brief counselling, case management, and liaison involving: communication, treatment coordination and referral between mental health services, other providers and GPs (Harmon, Carr & Lewin). They found that this service was highly accessible and acceptable to GPs who reported high levels of satisfaction. Findings from this investigation suggest that GPs would respond favourably to consultation liaison psychiatry nursing roles, however; responses of community nurses are yet to be ascertained.

42

In past literature, the consultation liaison psychiatry nursing role has been found to be highly effective in care collaboration and provision of focused expertise in mental health for varying groups of health professionals including nurses, doctors and allied health professionals in acute care focused inpatient settings (Brendon & Reet, 2000; Sharrock and Happell, 2001, 2002; Sharrock, Grigg, Happell, Keebl-Devlin & Jennings, 2006, Wand & Happell, 2001, 2002; Wand, 2004) and among GPs in primary care settings (Harmon, Carr & Lewin, 2000). Based on these findings it would be expected that the consultation liaison psychiatry nursing role would be as acceptable to and collaborative with health professionals in community contexts although the viewpoints of generalist community nurses remain unknown. This further suggests that a study appraising the experiences of nurses collaborating with community based consultation liaison psychiatry nursing roles would be an important addition to this developing knowledge base.

5.1.3 Effectiveness of Drug and Alcohol Nursing Roles

The literature regarding the effectiveness of the drug and alcohol nursing role was also considered as part of the current literature review to inform the drug and alcohol domains of the mental health drug and alcohol Clinical Nurse Consultant role for the care of people living with HIV/AIDS. Limited literature was identified with this nursing focus.

Past investigations have found that specialist alcohol liaison services improve alcohol treatment outcomes for people experiencing problems with alcohol use. In one of these studies, rates of completion of an alcohol rehabilitation program were significantly improved for those people who received an assessment by the specialist alcohol liaison service incorporating both nurses and psychiatrists when compared with assessment by a generic psychiatry liaison service (Hillman, McCann, & Walker, 2001). In a literature review (Nkowane & Saxena, 2004), found that drug and alcohol focused nursing care was found to effectively assisted people to manage their addiction upon discharge. They recommend that nurses expand their scope of practice to include drug and alcohol assessments and referral because of their engagement and partnership with clients in nursing care including assessment, health promotion and health prevention interventions. In a qualitative study aiming to describe the drug and alcohol nursing role, 6 drug and alcohol nurses working in an Australian inpatient setting were surveyed (Happell & Taylor, 1999). These nurse participants considered that they effectively assisted patients with drug and alcohol problems by focusing on how they would cope with their addiction following discharge. These nurses also liaised and consulted to generalist nurses on medical and surgical units, providing assessment and advice regarding behaviour management for patients with drug and alcohol problems presenting for physical health problems therefore these components of their role approximated consultation liaison psychiatry nursing roles.

No studies were identified which captured client/patients’ responses to the drug and alcohol nursing role in community contexts or the viewpoint of generalist community nurses to a consultation liaison drug and alcohol nursing role. The current investigation of a mental health drug and alcohol Clinical Nurse Consultant in the care of people living with HIV/AIDS in the community will thus contribute additional understanding and knowledge regarding this role and its potential effectiveness on client outcomes and on the collaborative practice with the nursing team.

5.2 HIV/AIDS Clinical Nurse Consultant Mental Health and Drug and Alcohol Role

The Mental Health Drug and Alcohol CNC was an advanced practice nursing role that was developed and trialled within the existing RDNS HIV/AIDS Model of Care. This role was an important addition to the existing HIV/AIDS Team of Clinical Nurse Consultants adding a specialist stratum of mental health and drug and alcohol nursing expertise to meet the highly complex and multifaceted care needs of the RDNS HIV/AIDS client group. Accordingly, the mental health drug and alcohol nursing role collaborated with generalist community nurses and other health professionals and emphasised consultation and liaison as defined within the literature (Happell & Taylor, 1999; Harmon, Carr &

43

Lewin, 2000; Minarik & Neesse, 2002; Norwood, 1998; Sharrock, Grigg, Happell, Keebl-Devlin & Jennings, 2006).

Consultation components of the Mental Health drug and alcohol CNC role were characterised by clinical care including: assessment, screening and treatment planning; clinical support and consultation to the RDNS HIV/AIDS Team and relevant field staff; and education for RDNS clients/carers and staff. Importantly, the Mental Health Drug and Alcohol CNC role also targeted health promotion and prevention education in relation to mental health issues and drug and alcohol difficulties for clients living with HIV/AIDS with a focus on risk identification, harm minimisation and prevention of transmission of HIV. The role thereby had a vital public health function in terms of reducing the risk of transmission of HIV infection.

Notably, the scope of practice of a mental health and/or drug and alcohol registered nurse varies considerably from that of a generalist registered nurse. The mental health and/or drug and alcohol nurse has the appropriate educational preparation and clinical experience to undertake specialised and focused assessments, including suicide and risk assessments, and therapeutic interventions appropriate to their focus of care. Alternatively, the generalist nurse is skilled and experienced in undertaking health assessments and screening, including screening for common mental health problems, and referral to specialist providers for focused assessment, including risk assessment, and specialised health interventions. Therefore, the Mental Health Drug and Alcohol CNC role developed and trialled within this project provided specialist focused mental health and drug and alcohol nursing care to people with HIV/AIDS and provided support to RDNS nurses. The supportive and educational role of the Mental Health Drug and Alcohol CNC in relation to the HIV/AIDS Team and RDNS generalist field nurses thus aimed to maximise the role of the generalist district nurse in facilitating optimal mental health and drug and alcohol nursing care (as appropriate to their scope of generalist nursing practice) by identifying mental health and drug and alcohol difficulties and referring them to the appropriate providers including the RDNS mental health drug and alcohol Clinical Nurse Consultant and GPs and discussing treatment with psychiatrists.

Liaison components of the mental health drug and alcohol CNC role comprised: referral (bidirectional) and focused care coordination, including for clients at significant risk of self harm, with mental health and drug and alcohol services thereby optimising the best fit between available services and clients’ health needs. This was particularly important in relation to clients with dual diagnoses, including mental health and drug and alcohol difficulties, who otherwise may have experienced considerable difficulty accessing either mental health or drug and alcohol services. The role therefore bridged gaps in current service delivery systems by facilitating liaison and care coordination between services including referral from RDNS nurses to external service providers such as general practitioners and mental health and drug and alcohol services.

Importantly, the mental health drug and alcohol nursing role was a community health nursing role as in addition to being based in the community it functioned in accordance with the primary health care principles of partnership and collaboration and targeted social determinants of health and illness in particular social factors known to negatively affect health and wellness for example poor housing and stigma prohibiting access to health services (Baum, 2002; Besner, 2004; Talbot & Verrinder, 2005). Therefore as anticipated, the Mental Health Drug and Alcohol CNC focused on improved management of health and social crises, as for example; related to suicide risk, related to challenging behaviours compromising housing arrangements, and as related to stigma. The role included education to mainstream mental health/drug and alcohol services targeting fear and stigma surrounding HIV/AIDS, and offered support and secondary consultation thereby collaborating and consulting with other providers including case managers. Additionally, an outreach service was provided by the Mental Health Drug and Alcohol CNC at the Positive Living Centre.

The Mental Health Drug and Alcohol CNC role encompassed a number of domains as relevant to the role of Clinical Nurse Consultant and within the current context of optimal management of the HIV/AIDS epidemic and related issues of harm and risk reduction. Therefore, the expertise of the

44

Mental Health Drug and Alcohol CNC as developed within the current project was used for both primary (client) and secondary (staff) consultations and focused on:

• Enhanced identification of mental health and drug and alcohol use problems for HIV/AIDS clients via screening and assessment including risk assessment (especially with regard to mental illness, suicide risk assessment and drug and alcohol use)

• Improved management of related health and social problems

• Enhancement of clients’ capacity to remain in the community

• Improved liaison with and care coordination across diverse health and social services: mental health services, drug and alcohol services and services focused on HIV/AIDS issues

• Provision of an outreach service to people living with HIV/AIDS maximising access to mental health and drug and alcohol services and targeting early identification and prevention of health and social crises related to mental health and drug and alcohol difficulties.

These elements were the subject of the evaluation undertaken in the current project.

45

6 Evaluation Findings

6.1 Case and Demographic Data During the four month client recruitment period, April to July 2007, a total of 119 clients were receiving RDNS care on the HIV/AIDS Program. Therefore, 119 clients were potentially available for recruitment. These clients were aged on average 46.9 years (sd=11.7), and 94 were males (79%), 24 females (20.2%) and 1 intersex (0.8%). Eight of these clients (6.7%) were Indigenous Australians or Torres Strait Islanders. The age range in years of this client group is presented in Figure 6.1.

Age Range70-7960-6950-5940-4930-3920-29

Coun

t

50

40

30

20

10

0

Figure 6-1 Age Range in Years for all RDNS Clients on the HIV/AIDS Program

The outcome of selection and recruitment processes for all clients available to participate in the project evaluation are presented in Table 6.1.

46

Table 6-1 Outcome of selection and recruitment processes (N=119)

Outcome N %

Agreed to participate/assessed 43 36.1

Declined 44 37.0

Ineligible 32 26.9

Three distinct subgroups of people emerge from data presented in Table 6.1 including those who:

• agreed to participate and were assessed; • declined including those who were discharged prior to invitation and those who declined further

assessment after completing the screening process; and • those who were ineligible/did not meet the selection criteria.

People were eligible to participate if they met the following selection criteria: Inclusion Criteria:

• Must be currently receiving district nursing care from RDNS HIV/AIDS Team on the HIV/AIDS program

• If cognitively impaired, clients on the HIV/AIDS program must have a carer • Must be aged 18 years or over


Additional analyses were undertaken in order to describe the demographic characteristics of each of these subgroups. Data in regards to age and gender for these three cohorts are displayed in Table 6.2. Percentages presented in Tables 6.2-6.7 have been calculated from the number of participants for the respective cohort.

The country of origin for people in the three cohorts including those who: agreed to participate/were assessed, declined, and were ineligible/did not meet selection criteria are presented in Table 6.3.

Carer availability data for these three groups are presented in Table 6.4.

47

Table 6-2 Age and gender (N=119)

Cohort

Demographic Characteristic

Agreed to participate/Assessed

(n=43)

Declined (n=44)

Ineligible (n=32)

Age in years mean (sd) 46.4 (10.2) 47.3 (10.6) 46.9 (14.9)

Gender n (%)

Male 36 (83.7) 34 (77.3) 24 (75.0)

Female 7 (16.3) 10 (22.7) 7 (21.9)

Intersex 0 (0) 0 (0) 1 (3.1)

Table 6-3 Country of origin (N=119)

Cohort n (%)

Country of Origin

Agreed to participate/

Assessed (n=43)

Declined (n=44)

Did not meet selection criteria (n=32)

Australia/ New Zealand

35 (81.4) 33 (75.0) 21 (65.6)

Other 8 (18.6) 11 (25.0) 11 (34.4)

48

Table 6-4 Carer availability (N=119)

Cohort

n (%)

Carer Availability


Assessed (n=43)

Declined (n=44)


Carer not needed 19 (44.2) 23 (52.3) 8 (25.0) Lives alone has a carer 1 (2.3) 0 (0) Lives alone with no carer 11 (25.6) 9 (20.5) 6 (18.8) Lives with another - resident carer

4 (9.3) 3 (6.8) 3 (9.4)

Lives with another - non resident carer

0 (0) 0 (0) 1 (3.1)

Lives with another- no carer 4 (9.3) 5 (11.4) 3 (9.4) Lives in mutually dependent situation

0 (0) 0 (0) 1 (3.1)


1 (2.3) 1 (2.3) 8 (25)

Not recorded 3 (7.0) 3 (6.8) 2 (6.3)

Living arrangement data are presented in Table 6.5 for the three subgroups.

Table 6-5 Living Arrangements (N=119)

Cohort

n (%)

Living Arrangements


Assessed (n=43)

Declined (n=44)


Lives alone 22 (51.2) 22 (50.0) 11 (34.4) Lives with family 13 (30.2) 13 (29.5) 7 (21.9) Lives with others 4 (9.3) 5 (11.4) 3 (9.4) Lives in special accommodation 1 (2.3) 2 (4.5) 8 (25.0) Not recorded 3 (7.0) 2 (4.5) 3 (9.4)

49

Of the 119 clients, 82 (68.9%) were recorded as having a mental disorder and 37 (31.1%) were not. Frequencies of mental disorders by cohort data are presented in Table 6.6.

Table 6-6 Frequency of Mental Disorders (N=119)

* Presents clients with at least one mental disorder therefore percentages are included.

Cohort n (%)


Assessed (n=43)

Declined (n=44)


Number with a mental health diagnosis*

32 (74.4)

30 (68.2)

20 (62.5)

Frequency data for the top four types of mental disorder for those who agreed to participate, those who declined and those not meeting the selection criteria are presented in Table 6.7.

Table 6-7 Frequency of Type of Mental Disorder (N=119)

Cohort

n (%*)

Mental Disorder


Assessed (n=43)

Declined (n=44)


Depression 23 (53.5) 17 (38.6) 11 (34.4) Substance Use Problems 12 (27.9) 13 (29.6) 8 (25.0) Anxiety 9 (20.9) 7 (15.9) 4 (12.5) Cognitive impairment and history of HIV dementia

6 (14.0) 0 (0) 5 (15.6)

Other 10 (23.3) 11 (25.0) 13 (40.6)

*Participants may have more than one disorder therefore percentages may add to more than 100%.

50

Nursing activities for 119 clients in the three cohorts are presented in Table 6.8

Table 6-8 Frequency and Type of Nursing Activities (N=119)

Cohort

n (%)

Nursing Activity*


Assessed (n=43)

Declined (n=44)


Medication management, health monitoring/support, health education/promotion, symptom/pain management

28 (65.2) 25 (56.8) 15 (46.9)

Health monitoring/support, health education/promotion, symptom/pain management

12 (27.9) 15 (34.1) 10 (31.2)

Wound Care, health monitoring/support, symptom/pain management

0 (0) 2 (4.6) 3 (9.4)

Continence including urinary catheter care

0 (0) 1 (2.3) 2 (6.2)

Not recorded 0 (0) 1 (2.3) 2 (6.3) *One activity per client Chi Square analyses were undertaken to compare those who agreed to participate, declined and those who were ineligible on gender, being born in Australia/New Zealand, living alone, and those for whom a mental health diagnosis had been recorded. Data for the person nominating themselves as ‘intersex’ were deleted from the analysis for gender in order to maintain the assumption of ‘minimum expected cell frequency’ (Pallant, 2002). For ease of interpretation, being born in Australia, living alone and having a mental health diagnosis were coded dichotomously. There were no significant differences between people who agreed to participate, declined and those who were ineligible according to gender, being born in Australia, living alone, or for those with a recorded mental health diagnosis. There was no significant difference on a one-way between groups analysis of variance to compare these groups of people on age. These findings indicate that people who agreed to participate were not significantly different from those who declined or who were not eligible based on their demographic characteristics.

6.2 Screening and Referral Data The previous section reported case and demographic data for three client cohorts including those who agreed to participate and were assessed, those who declined and those who were ineligible. In this section screening and referral data are presented. There were no missing data for the K10 questionnaire and Mini-mental State Exam for the 43 people who were assessed by the Mental Health Drug and Alcohol CNC, therefore these scores were summed and descriptive statistics computed. These data are presented in Table 6.9.

51

Table 6-9 Clinical Caseness for K10 and MMSE (n=43)

Score

Test

n (%) Above Clinical Cut off

Mean (sd)

K10 36 (83.7))* 26.5 (10.0) MMSE 43 (100.0) 28.5 (1.9)

* K10 scores of 16 or more are considered potentially clinically significant + MMSE scores below 23 are potentially clinically significant

6.3 Nursing Assessment Nursing assessment data for the 43 people who participated in an assessment by the Mental Health Drug and Alcohol CNC are presented in this section. Importantly, additional clients were assessed and received mental health and/or drug and alcohol focused interventions including crisis management, however; these clients did not meet the selection criteria for the evaluation and are therefore not represented in these nursing assessment findings.

Of the 43 people assessed as part of the evaluation, 28 (65.1%) were referred to the Mental Health Drug and Alcohol CNC by one of the 3 HIV/AIDS CNCs. The remainder were referred by one of the RDNS HIV/AIDS Resource Nurses and other centre-based nurses.

During the mental health drug and alcohol assessment, past and current mental health and substance use diagnoses and related treatment were appraised. Of the 43 people assessed, 30 people (69.8%) reported past treatment for a mental health and/or substance use problem. Descriptive data regarding mental health/substance use diagnoses treated in the past and the type of treatment are presented in Tables 6.10 and 6.11.

Current mental health and/or substance use difficulties and treatment were also reported by participants during the Mental Health Drug and Alcohol CNC assessment. In total, 15 people reported a current medical diagnosis of a mental health problem, 14 of which had been provided by the person’s medical practitioner. Descriptive data regarding current mental health/substance use diagnoses and current type of treatment are presented in Tables 6.12 and 6.13.

52

Table 6-10 Past mental health/substance use diagnosis (n=43)

Diagnosis n (%)

Depression 24 (55.8)

Anxiety 4 (9.3)

Bipolar 4 (9.3)

Psychosis including schizophrenia

2 (4.7)

Substance use 1 (2.3)

Dementia including HIV dementia

1 (2.3)

Other 6 (14.0)

Table 6-11 Past mental health/substance use treatment (n=43)

Treatment n (%)

Psychotropic medications 30 (69.8)

Counselling/psychotherapy 16 (37.2)

Inpatient psychiatry 14 (32.6)

Other 1 (2.3)

Table 6-12 Current mental health/substance use diagnosis (n=43)

Diagnosis n (%)

Depression 11 (25.6)

Anxiety 2 (4.7)

Bipolar 4 (9.3)

Psychosis including schizophrenia

1 (2.3)

Other 1 (2.3)

53

Table 6-13 Current mental health/substance use treatment (n=43)

Treatment n (%)

Psychotropic medications 18 (41.9)

Counselling/psychotherapy 12 (27.9)

ECT 0 (0.0)

Community treatment order 0 (0.0)

Other 3 (7.0)

6.3.1 Mental Health Drug and Alcohol CNC Activities

Nursing activities undertaken by the Mental Health Drug and Alcohol CNC during the data collection period were also recorded on the Nursing Assessment document. These activities included diverse nursing interventions, presented in Table 6.14, and referrals to external services and providers, presented in Table 6.15.

Importantly, all clients underwent a comprehensive mental health and drug and alcohol focused assessment and had a mental health and/or drug and alcohol focused care plan developed based on their assessment and in collaboration with their team of generalist nurses. Care plans were diverse and individualised to clients’ assessed needs and included: plans to manage challenging behaviours; discussions with clients, their families and carers regarding managing difficult behaviours and mental health symptoms; plans to increase the effectiveness of psychotropic medications and minimise any side effects including problems with sexual functioning; assisting clients with motivation to attend appointments with allied health providers including psychologists, counsellors and physiotherapists; care plans focused on risk management and safety for clients and for nursing staff; and a focus on practice reflecting the best available evidence in mental health and/or drug and alcohol nursing care.

Additionally, all clients participated in health promotion and health education focused on mental health and drug and alcohol usage. These interventions included: considering any mental health type questions to ask their GP, psychiatrist, or other mental health practitioner; education of clients and their families/carers regarding management of any side effects of medications; and education regarding cognitive and behavioural self-management strategies including anxiety reduction techniques (e.g. deep breathing, diverting attention to non anxiety provoking stimuli), identification of activities making them happy, and acceptance of difficult feelings. Of the 43 people who underwent an assessment as part of the project evaluation, 41 underwent a review and follow-up visit.

54

Table 6-14 Mental Health Drug and Alcohol CNC interventions (n=43)

Intervention n (%)

Assessment 43 (100.0)

Care plan 43 (100.0)

Client and carer education/health promotion

43 (100.0)

Monitor 38 (88.4)

Liaison with case manager 2 (4.7)

Review/follow-up 41 (95.0)

Other 8 (18.6)

Table 6-15 Referrals to external providers/services (n=43)

External provider n (%)

Mental health services 4 (9.3)

General practitioner 25 (58.1)

Victorian AIDS Council 10 (23.3)

Melbourne Sexual Health Centre 9 (20.9)

Local government 1 (2.3)

Other 35 (81.4)

6.4 Client Assessment and Follow-up Data In total, 43 people completed the assessment by the mental health drug and alcohol CNC including the DASS21, ASSIST, HONOS and WHOQoL bref. Of the 43 people assessed, 41 completed these measures at 6-8 weeks follow-up. Two people did not participate in follow-up data collection for two different reasons: one declined further participation in the project and the second person became unwell and was admitted to hospital. The assessment and follow-up data (n=41) are presented in this section as descriptive and exploratory analyses in order to describe the mental health and drug and alcohol use characteristics of this sample, and in order to appraise any changes in symptoms and self-reported quality of life.

All assessment measures were collected during the assessment visit in the client’s home and all follow up measures were collected at the one time during the follow-up visit. The average time between screening and assessment for client participants was 20.2 days (sd 20 days). On average, client participants underwent the follow-up visit 66.1 days after their assessment visit (sd 22.6).

55

56

Correlation data for all assessment measures and the K10 are presented in Table 6.16.

6.4.1 Depression Anxiety and Stress Scales (DASS21)

Forty-one people completed the DASS21 at assessment and at follow-up. There were a small number of missing data for the DASS21 collected at assessment (less than 10%); therefore items were imputed using mean substitution. Three analyses with paired samples t tests were undertaken to compare assessment and follow-up measures for each of the three DASS21 subscales: depression, anxiety and stress. All paired samples t tests were not significant indicating no change in participants’ depression, anxiety and stress self report symptoms. Mean scores for the assessment and follow-up DASS21 scores are presented in Table 6.17.

Additional analyses were undertaken to appraise peoples’ caseness using the cut off score for moderate symptom severity. Descriptive data are presented in Table 6.18. Comparisons were undertaken using McNemar’s Chi-square. The analyses revealed no significant change in caseness between assessment and follow-up.

Table 6-16 Correlations for the K10 and Assessment Measures - DASS21, ASSIST, HONOS and WHOQoL-bref (n=43)

K10 DASS21 Depress-ion

DASS21Anxiety

DASS21Stress

ASSIST Tobacco

ASSIST Alcohol

ASSIST Cannabis

HONOS Beh

HONOS Imp

HONOS Symp

HONOS Soc

WHO-QoL Physical Health

WHO-QoL Psychol-ogical Health

WHO-QoL Social Relation-ships

WHO-QoL Environ-ment

K10 1 - - - - - - - - - - - - - -

DASS21 Depression 0.81** 1 - - - - - - - - - - - - -

DASS21 Anxiety 0.71** 0.71** 1 - - - - - - - - - - - -

DASS21 Stress 0.75** 0.75** 0.80** 1 - - - - - - - - - - -

ASSIST Tobacco 0.38* 0.36* 0.20 0.24 1 - - - - - - - - - -

ASSIST Alcohol 0.43** 0.31* 0.28 0.31* 0.27 1 - - - - - - - - -

ASSIST Cannabis 0.12 0.15 0.24 0.31* 0.34* 0.23 1 - - - - - - - -

HONOS Behaviour 0.41** 0.35* 0.36* 0.37* 0.25 0.63** 0.58** 1 - - - - - - -

HONOS Impairment 0.20 0.18 0.16 0.19 0.11 0.24 0.23 0.39** 1 - - - - - -

HONOS Symptoms 0.61** 0.49** 0.39** 0.54** 0.20 0.23 0.34* 0.48** 0.21 1 - - - - -

HONOS Social 0.41** 0.39** 0.38* 0.36* 0.52** 0.15 0.28 0.27 0.39** 0.44** 1 - - - -

WHOQoL-Physical Health

-0.54** -0.38* -0.51** -0.55** -0.23 -0.16 -0.09 -0.14 -0.34* -0.48** -0.33* 1 - - -

WHOQoL-Psychological Health

-0.71** -0.78** -0.51** -0.64** -0.30 -0.27 -0.10 -0.34* -0.14 -0.66** -0.46** 0.51** 1 - -

WHOQoL-Social Relationships

-0.54** -0.59** -0.40** -0.62** -0.32* -0.06 -0.15 -0.12 -0.17 -0.42** -0.43** 0.43** 0.68** 1 -

WHOQoL-Environment

-0.67** -0.64** -0.58 -0.64** -0.49 -0.36 -0.32* -0.39* -0.28 -0.42** -0.42** 0.55** 0.63** 0.75** 1

** Correlation is significant at the 0.01 level (2-tailed) * Correlation is significant at the 0.05 level (2-tailed

57

Table 6-17 Mean scores for DASS21 collected at assessment and follow-up (n=41)

Score

DASS21 Subscale

Mean (sd) Assessment

Mean (sd) Follow-up

T Sig

Depression 19.7 (12.8) 19.2 (12.6) 0.37 NS Anxiety 13.5 (11.5) 14.1 (11.0) -0.54 NS Stress 18.8 (12.3) 19.3 (12.2) -0.28 NS

Table 6-18 Scores above cut off for DASS21 collected at assessment and follow-up (n=41)

Score DASS21 Subscale

n (%) Above Cut Off Assessment

n (%) Above Cut Off Follow-up

Depression 26 (63.4) 27 (65.9) Anxiety 23 (56.1) 25 (61.0) Stress 20 (48.8) 18 (43.9)

* Cut off scores nominated as moderate or above: 14 or more for the depression subscale, 10 or more for the anxiety subscale and 19 or more for the stress subscale

6.4.2 Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

The ASSIST was completed for 41 people at assessment and at follow-up. There were no missing data. A number of different scores can be calculated from the ASSIST. As the ASSIST subscales appraising the specific substance involvement score for each drug class are the most useful for screening and clinical purposes (WHO, 2003), these scores are used in the current analysis. Each of these ASSIST subscales provides a measure of the respondent’s use and problems for each respective substance. Additionally, the ASSIST subscales provide an indication of the risk of future problems related to substance use. The number of people using alcohol or drugs at least once in the 3 months preceding assessment and in the 6-8 week interval between assessment and follow-up are presented in Table 6.19.

Analyses with paired samples t tests were undertaken to compare assessment and follow-up measures for three of the ASSIST subscales: Tobacco, Alcohol, and Cannabis. Assessment and follow-up data for the remaining ASSIST subscales: Cocaine, Amphetamines, Inhalants, Hallucinogens, Opioids and Sedatives; were not compared as there were insufficient data to warrant analysis. All paired samples t tests were non-significant indicating no change in participants’ drug and alcohol scores between assessment and follow-up. Mean scores for the assessment and follow-up scores for the ASSIST subscales: Tobacco, Alcohol and Cannabis are presented in Table 6.20.

58

Table 6-19 Descriptive statistics for people using alcohol and/or drugs at assessment and follow-up (n=41)

ScoreASSIST Subscale n (%) using

drug/alcohol Assessment *

n (%) using drug/alcohol Follow-up *

Tobacco 29 (70.7) 29 (70.7)

Alcohol 32 (78.0) 26 (63.4)

Cannabis 20 (48.8) 16 (39.0)

Cocaine 0 (0.0 ) 5 (12.2)

Amphetamines 8 (19.5) 6 (14.6)

Inhalants 7 (17.1) 7 (17.1)

Sedatives 1 (2.4) 3 (7.3)

Hallucinogens 0 (0.0) 1 (2.4)

Opioids 3 (7.3) 5 (12.2)

* Includes people who have used drugs or alcohol once or more in the past 3 months for assessment data, or since the initial assessment visit for follow-up data. Participants may use more than one drug/alcohol, therefore percentages may add to more than 100%.

Table 6-20 Mean scores for ASSIST at assessment and follow-up (n=41)

Score

ASSIST Subscale

Mean (sd)

Assessment

Mean (sd)

Follow-up

t Sig

Tobacco 14.7 (11.1) 15.4 (11.4) -0.7 NS

Alcohol 6.6 (7.4) 5.8 (8.0) 0.9 NS

Cannabis 5.1 (7.9) 3.9 (6.2) 1.1 NS

Further analyses were undertaken for scores above the cut off for moderate risk related to drug and alcohol use. These descriptive data are presented in Table 6.21. The top three most frequently used substances: tobacco, alcohol, and cannabis; were considered for comparison. However; as there was no change in the number of people scoring above the cut off at assessment and follow-up for tobacco and cannabis, comparisons were not undertaken for these subscales. McNemar’s Chi-square was used to compare the number of people using alcohol above the cut off score at assessment and follow-up. There was no significant difference indicating no change.

59

Table 6-21 Scores above cut off for ASSIST at assessment and follow-up (n=41)

Score

ASSIST Subscale

n (%) Above Cut Off

Assessment

n (%) Above Cut Off

Follow-up

Tobacco 28 (68.3) 28 (68.3)

Alcohol 9 (22.0) 8 (19.5)

Cannabis 13 (31.7) 13 (31.7)

Cocaine 0 (0.0) 1 (2.4)

Amphetamines 7 (17.1) 6 (14.6)

Inhalants 2 (4.9) 1 (2.4)

Sedatives 1 (2.4) 3 (7.3)

Hallucinogens 0 (0.0) 0 (0.0)

Opioids 2 (4.9) 3 (7.3)

The following cut off scores indicated moderate risk or above: 11 or more for alcohol, and 4 or more for all other substances (WHO, 3002).

6.4.3 Health of the Nations Outcomes Scales (HONOS)

The HONOS was completed for 41 people at assessment and at follow-up. There were no missing data. The HONOS subscales provide more detailed information than the total score representing overall symptom severity and functional difficulty. Therefore, the four subscales: Behavioural Problems (aggression, self-harm, and substance use), Impairment (cognitive dysfunction and physical disability), Symptomatic Problems (hallucinations, delusions, depression and other symptoms), and Social Problems (personal relationships, overall functioning, residential problems and occupational problems); were compared at assessment and at follow-up using paired samples t tests. A significant result was found for the Social Problems subscale indicating that people’s social problems had improved at follow-up. Analyses for Behavioural Problems, Impairment and Symptomatic Problems were not significantly different at follow-up indicating no change. These data are presented in Table 6.22.

Table 6-22 Mean scores for HONOS collected at assessment and follow-up (n=41)

Score

HONOS Subscale


Mean (sd) Follow-up

T Sig

Behavioural Problems 0.8 (1.0) 0.9 (1.7) -0.61 NS Impairment 1.6 (1.4) 1.4 (1.4) 1.19 NS Symptomatic Problems 2.0 (1.2) 1.8 (1.2) 0.96 NS Social Problems 3.4 (2.1) 2.5 (2.0) 3.21 p<0.01

60

Further analyses were undertaken to appraise peoples’ scores above and below the cut off score for moderate problem severity. The four HONOS subscales for assessment and follow-up data were coded dichotomously and comparisons undertaken using McNemar’s Chi-square. Impairment and Social Problems were significantly different indicating that fewer participants scored below the cut off for these two subscales at follow-up. Behavioural Problems and Symptomatic Problems were not significantly different suggesting no change in these HONOS domains at follow-up. These data are presented in Table 6.23.

Table 6-23 Scores above cut off for HONOS collected at assessment and follow-up (n=41)

Score HONOS Subscale

n (%) Above Cut

Off Assessment

n (%) Above Cut Off Follow-

up

McNemar’s Chi-square

Sig

Behavioural Problems 3 (7.3) 4 (9.8) 0.20 NS Impairment 13 (31.7) 7 (17.1) 6.00 p<0.01 Symptomatic Problems 15 (36.6) 8 (19.5) 3.27 NS Social Problems 28 (68.3) 16 (39.0) 10.29 p<0.01

* The following cut off scores indicated moderate problem severity or above: 3 or more for all subscales (Eagar et al., 2000).

6.4.4 Quality of Life (WHOQoL bref)

Forty-one people completed the WHOQOL bref at assessment and at follow-up. There were a small number of missing data collected at assessment and follow-up for all four WHOQOL subscales (less than 10%); therefore items were imputed using mean substitution. As items 3, 4, and 26 are negatively worded, these were reversed scored for assessment and follow-up data (Murphy et al., 2000). For ease of interpretation, raw domain scores were transformed to a 0-100 scale following the formula provided in the User’s Manual and Interpretation Guide (Murphy et al., 2000). Four analyses with paired samples t tests were undertaken to compare assessment and follow-up measures for each of the transformed WHOQOL bref subscales appraising subjective quality of life in the following domains: Physical Health, Psychological Health, Social Relationships, and Environment. There were no significant differences indicating no change. Mean scores for the assessment and follow-up WHOQOL scores are presented in Table 6.24.

61

Table 6-24 Mean scores for WHOQOL bref at assessment and follow-up (n=41)

Score

WHOQOL bref Subscale


Mean (sd) Follow-up

T Sig

Physical Health 46.3 (19.2) 48.5 (16.3) -0.95 NS Psychological Health 49.4 (19.8) 46.1 (22.6) 1.39 NS Social Relationships 44.5 (25.0) 46.6 (27.1) -0.56 NS Environment 55.3 (21.4) 57.5 (20.1) -0.89 NS

6.5 Client Satisfaction Findings

6.5.1 Client Satisfaction

In total, 42 participants were sent a client survey. These 42 people were all those who participated in an assessment by the Mental Health Drug and Alcohol CNC. One person participated in an assessment by the Mental Health Drug and Alcohol CNC and then subsequently declined further participation. A client survey was therefore not sent to this person. A repeat client survey was sent two weeks after the first survey to all non responders which resulted in a substantial increase in returned surveys. Of the 42 client surveys sent, 25 people returned completed surveys constituting a response rate of 60%. Respondents were aged on average 48.6 years (sd 8.8 years) and 21 (84.0 %) were male.

Of the 25 client respondents, 15 provided written comments regarding the best features of the Mental Health Drug and Alcohol Clinical Nurse Consultant service. These responses were coded into three themes:

• Education

• Caring, support, and reassurance

• Liaison and referral

These data are presented in Table 6.25.

Three of the 25 clients provided written comments regarding suggested improvements to the Mental Health Drug and Alcohol Clinical Nurse Consultant service. These responses were coded into one theme:

• More contact and self-help strategies

These data are presented in Table 6.26.

Two respondents noted that the service did not need to improve as:

“In my view not a thing, well done RDNS I could not have gotten through the last 12 months with out all your fantastic staff. Thank you so much.”

“I do not think there is any need for improvement, the service is excellent.”

62

Table 6-25 The best feature of the Mental Health Drug and Alcohol Clinical Nurse Consultant service (n=25)

Theme Client comment

Education “The consultant helped me to better understand my disorder.”

“The consultant made me feel comfortable. And I did get knowledge.”

“My initial response was guarded not knowing what to expect from the consultant. I relaxed and found discussion about mental health issues interesting and enlightening.”

Caring, support and reassurance

“Personable, Good listener.”

“The time, caring, understanding and privacy.”

“At moments of high stress the MH CNC was able to come to my home to advise and calm me. This helped me reinstate my self control.”

“Understood where I was coming from.”

“I was happy that the mental health nurse came to see me.”

“Being able to talk to the consultant. The consultant was very thorough and efficient.”

“Having someone to discuss the various mental health issues connected with living with HIV. It is important to separate the medical and the psycho-social issues. Apart from affecting our physical health the virus impacts on our mental health beyond the realm of the counselling provided.”

“Knowing that they’re there.”

“Time didn’t matter when they came; they didn’t go quickly and always stayed for a while.”

“Having a trustworthy, confidential and reliable service with knowledgeable people.”

Liaison and referral “The liaison between the service and the Alfred Hospital and Fairfield House.”

“Someone looking at the mental health aspect. Having prior knowledge of my history and understanding what services were available. When I was diagnosed with HIV we were told not to tell or trust people other than our treating doctors. There was no mental health help available in the early 80s and this meant that we ‘totally bottled our emotions’”.

63

64

Table 6-26 Suggested improvements to the Mental Health Drug and Alcohol Clinical Nurse Consultant service (n=25)

Theme Client comment

More contact and self-help strategies

“I would like more contact.”

“I would like to see him more often.”

“I would like more options with regard to helping myself with my mental health issues.”

Descriptive statistics representing clients’ responses to the survey items are presented in Table 6.27. Three respondents commented that they had endorsed ‘not applicable’ for a number of questions as they did not need referral or follow-up, and as they had received two visits only. One client respondent reported mild dissatisfaction with the Mental Health Drug and Alcohol Clinical Nurse Consultant service on a number of items and reported: “I don’t think the consultant understood me enough”.

Table 6-27 Responses to the Client Satisfaction Survey at Follow-up (n=25)

Score n (%)Survey Item Satisfied Mildly

Satisfied Mildly

Dissatisfied Mostly

Dissatisfied Neutral/Uns

ure Not

Recorded Overall satisfaction with the quality of the Mental Health Drug and Alcohol CNC service.

20 (80.0) 4 (16.0) 0 (0.0) 0 (0.0) 1 (4.0) 0 (0.0)

Satisfaction that the Mental Health Drug and Alcohol CNC service was timely. 18 (72.0) 6 (24.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.0) Satisfaction with the questions asked by the Mental Health Drug and Alcohol CNC at the beginning of care.

19 (76.0) 6 (24.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

Satisfaction that the Mental Health Drug and Alcohol CNC listened and was understanding.

19 (76.0) 4 (16.0) 1 (4.0) 1 (4.0) 0 (0.0) 0 (0.0)

Satisfaction that the Mental Health Drug and Alcohol CNC was competent and knowledgeable.

22 (88.0) 3 (12.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

Satisfaction that the respondent’s opinions and choices were respected by the Mental Health Drug and Alcohol CNC

21 (84.0) 3 (12.0) 1 (4.0) 0 (0.0) 0 (0.0) 0 (0.0)

Satisfaction with the amount of help received. 17 (68.0) 5 (20.0) 2 (8.0) 0 (0.0) 1 (4.0) 0 (0.0) Satisfaction that the Mental Health Drug and Alcohol CNC service helped the respondent to deal more effectively with mental health problems.

13 (52.0) 7 (28.0) 3 (12.0) 0 (0.0) 2 (8.0) 0 (0.0)

Satisfaction with care options received from the Mental Health Drug and Alcohol CNC.

12 (48.0) 7 (28.0) 2 (8.0) 0 (0.0) 4 (16.0) 0 (0.0)

Satisfaction with referral options received from the Mental Health Drug and Alcohol CNC.

11 (44.0) 6 (24.0) 2 (8.0) 0 (0.0) 5 (20.0) 1 (4.0)

Satisfaction with information received from the Mental Health Drug and Alcohol CNC.

16 (64.0) 5 (20.0) 2 (8.0) 0 (0.0) 1 (4.0) 1 (4.0)

Satisfaction that care received from the Mental Health Drug and Alcohol CNC met the respondent’s expectations.

18 (72.0) 4 (16.0) 2 (8.0) 0 (0.0) 0 (0.0) 1 (4.0)

65

66

6.6 Client Interviews A total of 15 people were selected from the 42 people who agreed to receive a client survey. All 42 clients’ Unit Record Numbers were entered into an SPSS database and 25 people were randomly selected for invitation to participate in an interview. One interview was not undertaken as the client cancelled the interview due to lack of time. Fourteen interviews were undertaken with clients in the community. Thirteen client interviewees were males, aged on average 47.1 years (sd = 9.1 years).

6.6.1 Theme analysis

The 14 interviews were audio recorded and transcribed for analysis. A thematic analysis of each transcript resulted in the following four themes:


2. Enhanced support



Each of these themes is elaborated to follow and example quotes provided.


All fourteen client interviewees considered that the Mental Health Drug and Alcohol CNC role provided effective and empathic mental health care. Interviewees explained that the role provided vital and valuable mental health support which was non-judgemental, thoughtful and caring. Interviewees discussed feeling comfortable to talk to the Mental Health Drug and Alcohol CNC and all reported feeling listened to and feeling that they were understood. They found the role was efficient, reliable and responsive to their mental health needs. According to a number of clients, reflecting on thoughts and feelings was helpful as it assisted in establishing a routine for their day, having a positive outlook and considering plans for their future. People reported feeling confident in the Mental Health Drug and Alcohol CNCs ability to advocate for them. They explained feeling reassured and a sense of calm following visits from the Mental Health Drug and Alcohol CNC.

“You can just open up to yourself a lot more....you can discuss any issue without being judged.”

“The [Mental Health Drug and Alcohol CNC] was genuinely caring.”

“Being understood, knowing that [the Mental Health Drug and Alcohol CNC] is familiar with my case so he’d be especially useful in the future. Because I can speak openly and freely to [the Mental Health Drug and Alcohol CNC] as a reference point in the future, [the Mental Health Drug and Alcohol CNC] will be able to be my spokesman, my advocate.”

“[The Mental Health Drug and Alcohol CNC] is a great listener...and has really helped to set my mind at ease...lots of empathy.”

“It added to the holistic treatment of someone, of me, it was so important that the mind was also included in all the physical stuff that was actually happening to me.”

67

2. Enhanced support

Client participants commented on enhanced support following assessment and care provided by the Mental Health Drug and Alcohol CNC. They reported relief from feelings of isolation, and explained that talking with a caring health professional relieved their sad feelings as it lessened their sense of burden, was comforting and reassuring, had an effect of normalising their experience and helped them to feel better. A number of interviewees explained that they were able to solve psychological problems by talking about them with the Mental Health Drug and Alcohol CNC. Other participants commented on the value of being able to talk about their psychological health during the assessment process and identify how they were feeling in order to consider strategies to manage difficult feelings. All client participants found that the role provided emotional support. According to one participant, acknowledgement of difficult feelings validated what the person had been through. Another person reported that they found the opportunity to talk and think validated them as a whole person. All participants reported that they valued being able to talk to the Mental Health Drug and Alcohol CNC about their difficulties.

“I would have been more isolated and isolation has become a real problem. I guess the [Mental Health Drug and Alcohol CNC] has given me an increased sense of my care and it’s not only tablets it’s your psychological well being. You know it’s all part and parcel of care. The psychiatric side of it is much more of a problem to me on a daily basis than any medical problem.”

“When [the Mental Health Drug and Alcohol CNC] left I thought I feel better now and it’s a good feeling. You’ve got it out which I think does you good.”

“To know that it was normal and just the responses and it lightened my mood a lot and gave me confidence in where I was heading and what I’d thought about my progress was confirmed so that was good.”

“It stopped me carrying the burden as much and bottling it up.”

“Well that was the difficult path, I think that [the Mental Health Drug and Alcohol CNC] gave some acknowledgement to what you’d been through and so because these are not nice emotions that just makes you feel better and it actually made me feel a bit more energised, you know it validated me.”


Client participants explained that they found the health promotion education provided by the Mental Health Drug and Alcohol CNC helpful in relation to their psychological health, drug and alcohol use and symptoms re their psychiatric illness. They considered that the Mental Health Drug and Alcohol CNC was knowledgeable about mental health, took time to explain, was understanding and listened to clients. Participants reported that they found the education helpful as it reassured them and alleviated their anxiety, helped them cope better on a day to day basis and helped them plan activities. Several people with a history of major mental illness reflected that the Mental Health Drug and Alcohol CNC education assisted them to better understand their mood swings. Interestingly, according to two clients the Mental Health Drug and Alcohol CNC increased their awareness of depression and assisted them to change their perception of mental illness thereby de-stigmatising mental health.

“[The Mental Health Drug and Alcohol CNC] is very knowledgeable and informed me of some of the characteristics that I didn’t know that I was suffering. I found it so helpful. I need that information, the more I know the better I can cope.”

“And it’s just made me a little bit more aware that possibly we can be suffering from depression or things like that and not really recognise it as such.”

68

“[The Mental Health Drug and Alcohol CNC] understood what I have been diagnosed with and discussed some of the long-term implications of this. So it is not so stressful and worrying. With [the Mental Health Drug and Alcohol CNC] saying a few things it’s not playing on my mind as much.”

4. Limitations and Improvements

All 14 participants reported that there were no limitations to the Mental Health Drug and Alcohol CNC role. Several participants commented on improvements to the role:

• Increased marketing of the role to inform more people of it’s availability, services offered and how to access the role

• More visits to provide supportive counselling

“I think that people should be told that there is someone available.”

6.7 Focus Group Interview One focus group was conducted in October 2007 with eight RDNS clinicians who had collaborated in care provision with the Mental Health Drug and Alcohol CNC over the trial of the role. The clinicians included four Clinical Nurse Consultants, one social worker, and three care manager nurses.


The focus group interview was audio recorded and transcribed for analysis. A thematic analysis of this transcript identified five themes:






Each of these themes is elaborated to follow and example quotes are presented:


Focus group participants considered that clients living with HIV/AIDS frequently experience mental health drug and alcohol problems including anxiety, depression, suicide and suicide attempts, abuse of: cannabis, amphetamines and alcohol; and drug induced psychosis. They explained those clients’ mental health difficulties and problematic drug and alcohol use typically affects: their behaviour and ability to live with others; ability to manage finances including purchasing basic food supplies; and clients’ psychosocial functioning. Additionally, focus group participants discussed frequent crises experienced by clients living with HIV/AIDS and co morbid mental health and drug and alcohol problems which were often triggered by use of illicit drugs. According to focus group participants, clients with co morbid mental health drug and alcohol problems were more likely to be socially isolated and experience unstable accommodation and eviction due to their challenging behaviours. These difficulties were further compounded by clients declining referral to mental health and/or drug and alcohol services. Focus group participants explained that it is challenging to provide effective care for clients with HIV/AIDS and co morbid mental health drug and

69

alcohol problems due to the impact of clients’ psychosocial difficulties and behaviours on their health such as inability to manage their HIV medications. They reported that clients’ mental health difficulties require addressing before they can be commenced on anti-retroviral medications or to maximise the ability to adhere with their existing medication regimes.

“I’d say some of the other mental health issues were suicide and actual suicide attempts, in relation to drugs it would mainly be things like marijuana and also amphetamine use and sometimes triggering psychotic type reactions and we had to deal with the seriousness of that.”

“A good example would be the one where one of our clients started to use amphetamines and then was slowly over time getting more and more psychotic but refusing to have any psychiatric intervention and assessment or even leave the house to the point where we ended up having to call the police to get her assessed. That’s one thing, or suicide attempts, we’d get a phone call, you know, I’ve taken a box of Panadol on a Friday afternoon or on Christmas eve, you know, things like that.”

“So certainly the stability of mental health can affect social functioning – a client comes to mind – he’s quite unstable and abusive towards other people and that certainly affects how other people react to him and also makes him more isolated because of that. Also clients who have been involved in drugs and alcohol it affects them financially as well which means that they struggle from day to day to make ends meet and pay bills and survive and get food. We get them food vouchers and things just to keep them going. It’s a constant struggle to keep their head above water so to speak. Just when you think things are going smoothly they’ll be struggling again.”


Focus group participants described caring for clients with HIV/AIDS and co morbid mental health drug and alcohol problems before commencement of the Mental Health Drug and Alcohol CNC role. They emphasised effective use of existing RDNS ‘at risk’ procedures and shared care between the RDNS social workers and nurses in managing clients experiencing psychosocial crises however; also noted that the RDNS social worker service is confined to short-term interventions due to limited resources. Focus group participants further explained their experience of caring for clients’ mental health difficulties as beyond their generalist scope of practice. They commented that they felt frequently overwhelmed and uncertain that care they were providing was appropriate and effective for their clients, and they experienced frequent difficulty accessing effective mental health and drug and alcohol services for their clients including difficulty communicating with mental health and drug and alcohol services.

Focus group participants explained a number of barriers for clients with HIV/AIDS and co-morbid mental health drug and alcohol problems. They considered that clients have difficulty accessing mental health and drug and alcohol services as these services work independently of each other and where clients experience both mental health and drug and alcohol problems they fall between both services as neither will provide a service to people with dual diagnoses. Focus group participants further commented that clients with mental health and/or drug and alcohol difficulties often have challenging behaviours and this also impairs their access to mental health and drug and alcohol services. They also reported that generalist nurses have limited understanding of and care collaboration with mental health and drug and alcohol services which inhibits access to these services on clients’ behalf or promotion/education of clients accessing these services themselves. Importantly, focus group participants explained that the stigma regarding mental health is an additional barrier for clients with mental health needs accessing appropriate services. They explained that some clients with mental health difficulties declined a visit from the Mental Health Drug and Alcohol CNC due to stigma and this was particularly noted with a number of clients from culturally and linguistically diverse backgrounds.

70

“If they are going through an acute mental health issue they won’t be managing with their HIV meds as well usually and quite often it’s the case that you can’t even consider starting them on a regime of anti-retrovirals unless those issues are addressed first. You know that they won’t be able to adhere to the regime, that’s a very big issue for us.”

“And trying to access the services and to use the right language to actually be able to persuade them to attend and not just be told ring the police which is quite a common response.”

“A little bit scary at times, just wondering whether you were managing correctly, if you’re not dealing with that sort of thing all the time then it can be quite confronting.”

“And that for me was the most frustrating thing, the ones that actually declined the service in my area potentially would have benefited from the service more than others.”

“I think that the service system - actually that meeting of the two service systems mental health and drug and alcohol there are some known gaps and these clients actually cross those gaps. So if you as a worker don’t have expertise in both, it can be a real challenge.”


Focus group participants all commented on the effectiveness of the Mental Health Drug and Alcohol CNC role for clients and for nurses collaborating in care provision. They explained how the role improved access to mental health and drug and alcohol assessment and care within the context of the client’s ability to function in their own home. This empowered clients, including those with cognitive impairment, and assisted to maintain clients in the community. According to focus group participants, the combination of mental health and drug and alcohol expertise within the Mental Health Drug and Alcohol CNC role was vital to effective community-based nursing care for people living with HIV/AIDS and co morbid mental health and/or drug and alcohol problems. This was due to focused mental health assessment and identification of clients’ care needs including behavioural care needs, and due to care plan development and nursing interventions targeting: challenging behaviours; psychotropic medication management; and consultation and liaison with other health professionals such as clients’ psychiatrists. Importantly, focus group participants all noted that care for cognitively impaired clients improved as the Mental Health Drug and Alcohol CNC was able to advocate for them by identifying their behavioural care needs. Interestingly, focus group participants all agreed that the role had potential to assist in reducing the risk of HIV transmission due to improved behaviour management of clients. Focus group participants all commented that the Mental Health Drug and Alcohol CNC role assisted clients to receive quick and timely care and treatment which avoided crises and lengthy hospitalisation. Additionally, focus group participants discussed the importance of the Mental Health Drug and Alcohol CNC role in empowering clients via health promotion and health education. Clients were thereby assisted to recognise their own mental health symptoms, anticipate their own crises and manage their problems themselves. Focus group participants explained how clients could access the Mental Health Drug and Alcohol CNC via the outreach service provided at the Positive Living Centre with a number of clients travelling long distances to do so. They all commented that the role was acceptable to most clients. They further explained that the role assisted clients and nurses to understand available mental health and drug and alcohol services and how they could access these services.

“You can actually manage and pre-plan for a lot of the crises if you have all the knowledge and the resources available ...- That is what the Mental Health Drug and Alcohol CNC has taught me.”

“Getting them into services, mental health and drug and alcohol services - that’s partly to do with our limited knowledge of the networks - which is now much better.”

71

“I think recognising cognitive impairment assists in the approach, you approach their situation differently because of understanding their behaviour and how it’s affecting people around them. [The Mental Health Drug and Alcohol CNC] was particularly good with these clients and the services that are dealing with them ...and to help guide these behaviours to a more acceptable sort of level.”

“I noticed that [The Mental Health Drug and Alcohol CNC] was very good with boundaries and also, as I mentioned before, knowing what’s achievable for a particular client.”

“Well I’ve certainly seen one of my clients as being able to access [The Mental Health Drug and Alcohol CNC] when the chips are down so to speak, the client knows that there is somebody within our service that can actually see him in the community and I guess assisting staying in the community, which is our role as district nurses, keep people in the home [The Mental Health Drug and Alcohol CNC] is an important part of that... Getting their unstable mental health treated rapidly so they can go in and come back out quickly rather than getting to a crisis point where they may endanger themselves or be hospitalised for a long period of time.”

“Also the effectiveness of the treatment and mental health medications, whether they’re actually working or whether they should be on something else and being able to explain that to the psychiatrist.”


All focus group participants explained that the Mental Health Drug and Alcohol CNC role was collaborative with the HIV/AIDS CNC team and with other nurses and social workers providing care to people living with HIV/AIDS. They considered that the role was accessible to staff, improved care planning and nursing interventions, avoided crisis situations for clients and empowered nurses to assist clients with co morbid mental health and/or drug and alcohol difficulties due to enhanced problem identification and a consistent approach to care. Focus group participants all noted that they felt comfortable to share care with the Mental Health Drug and Alcohol CNC and found the education helpful and effective as it promoted their confidence in caring for clients with complex care needs. They further explained their expectation that education in mental health would enhance their ability to care for other clients at RDNS with co morbid mental health difficulties. According to focus group participants, the role was a vital resource for generalist nurses.

“Accessing mental health services is about talking the language and being able to do that, that’s a useful thing to have someone there that can do that on your behalf. But also involve you in the process so that you learn more about how you actually access services when you need services.”

“I had a new resource nurse start with me and I’ve watched how one visit with [the Mental Health Drug and Alcohol CNC] and I’ve watched her grow and empower and be more confident and that extends into RDNS.”

“It was really beneficial when we had a case conference with the services involved – quite a number of services - and they would bring up various issues about his behaviour. ... and to actually see somebody with the know how to actually say well this is what he needs.”


Focus group participants identified the main limitations to the Mental Health Drug and Alcohol CNC role as the limited time to develop the role, the project was funded for 12 months, and project requirements

72

including the evaluation requiring collection of data. This resulted in limited time for: rapport to be developed with RDNS clients living with HIV/AIDS; and to demonstrate direct benefits of the role to clients. Additionally, the educational component of the role was somewhat limited as there was insufficient time to provide more extensive Centre-based in service group education regarding particular mental health and drug and alcohol difficulties for clients and recommended management strategies. A number of focus group participants commented on the difficulties for staff at all 20 metropolitan based RDNS Centres to be aware of the Mental Health Drug and Alcohol CNC due to insufficient time to regularly visit each Centre and promote the role.

“The group education was on hold because of the data collection.”

Focus group participants considered that the Mental Health Drug and Alcohol CNC role would improve with additional development in the field. They explained that the 12 month development and trial of the role is an underestimation of the full potential of the role which could be further developed to engage clients and promote the role with nursing staff including provision of Centre-based education sessions.

“On a one-to-one it’s been really effective, but we’re about to go up to the next level with teaching behavioural management at a Centre level.”

“The Mental Health Drug and Alcohol CNC has done a couple of talks...but is going to do a lot more...that’s something that is still in development.”

6.8 Phone Interviews Seven phone interviews with external health providers were conducted in October 2007 with people who had collaborated in care provision with the Mental Health Drug and Alcohol CNC over the trial of the role. This convenience sample included psychiatric nurses and other health professionals including managers of services for volunteers from varying agencies specialising in HIV/AIDS and mental health/drug and alcohol care: Victorian AIDS Council, Department of Human Services and an HIV/AIDS mental health provider.


Each interview was audio recorded and transcribed for analysis. A thematic analysis of this transcript identified four themes:





Each of these themes is elaborated to follow and example quotes are presented:


All seven interviewees commented that the Mental Health Drug and Alcohol CNC role added value to the community team providing care for people living with HIV/AIDS as the role was accessible and available. Interviewees explained that the role increased access to mental health services, provided a valuable outreach service to clients and resulted in strong partnerships with other community based providers. Importantly, interviewees explained that the role was of particular value as it was community-based. Interviewees reported that the community perspective of the role was valuable as it increased access and

73

availability to mental health drug and alcohol focused assessment and care planning for other community providers which was more applicable to their clients as it was specific to the community context. Interestingly, according to one interview participant, the role resulted in more effective triage in the community and improved the use of mental health and HIV services in the acute care context as there was less need for clients who were not severely unwell to attend hospital for assessment and advice re management plans as this had already been undertaken in the community.

“I didn’t really know how to access services, so I could identify there was an issue or a problem but I didn’t know how to get them into the system quickly enough and It was really good having someone like [the Mental Health Drug and Alcohol CNC] around who speaks the same language as psychiatry.”

“People behave differently in the community than in the hospital...we need people with mental health drug and alcohol experience and expertise to support the people who come here.”

“So we were able to go out in the community and work together to see the person at home and really assess what their current state is and their current needs. Hospital workers are much less able to get out in the community.”

“It’s decreased a lot of the inpatient need for psychiatry and HIV as it’s been dealt with more appropriately in the community by the [Mental Health Drug and Alcohol CNC]”

“So we’re able to go out together in the community working together to see the person at home and really address what their current state is and their current needs.”


All interviewee participants explained that the Mental Health Drug and Alcohol CNC role effectively collaborated consulted and liaised with them. They explained that the role was part of the team of providers in HIV/AIDS care. In particular, interviewees commented on the responsive assessment and timely feedback re assessment findings, helpful and practical suggestions for care plans, advice re referral and timely follow-up. They considered the availability of the Mental Health Drug and Alcohol CNC role in undertaking joint home visits on occasion for safety assessments re introduction of volunteers. Interviewees reported that the role provided helpful direction and care management plans for support workers and helpful training regarding challenging behaviours for their workers. They commented that the role was an effective resource for their service, provided valuable consultation to their staff and participated in case management meetings facilitating an open exchange of ideas re care plan changes. Overall, participants explained that the Mental Health Drug and Alcohol CNC role provided vital mental health drug and alcohol focused support for their team.

“We think [the Mental Health Drug and Alcohol CNC] was very worthwhile and provided a real bonus to our care.”

“I suppose what it boils down to is it’s given us the capacity and the confidence to work with some clients who we would otherwise have rejected.”

“It’s been a resource for me and other staff here. We’ve been able to run past him – this is what we’re doing, what do you suggest.”

74

“Consultation, being able to consult about where someone is at and what we could do and when we could go were brilliant, so some support for staff was fantastic.”

“Also assisting people to understand what is going on for the client as well that their behaviour might not just be difficult and annoying but it’s an outcome of the issues that they’re dealing with be it their mental health, their drug and alcohol usage, long-term living with a now chronic illness and also the stresses associated with being on a pension and having limited income and also an understanding that medications can impact in different ways.”


All interviewees considered that the Mental Health Drug and Alcohol CNC role improved care for clients in the community. They explained that the role provided accessible and efficient focused mental health and drug and alcohol assessments including for cognitively impaired people and in relation to clients’ functioning with their complex medication regimes. These assessment findings were then reported back to relevant external providers and care plans and reviews were considered at informal meetings and during more formal case meetings. Interviewees explained that assessment and care planning facilitated effective referrals to and liaison with mental health services and resulted in more effective discharge planning for hospitalised clients back to the community. Importantly, a number of interviewees explained that the role increased community service availability for clients regarding access to volunteer and support services as the focused assessment and care plan appraised client risk issues, commenced a risk management plan and defined clear parameters for support services. According to these interviewees, prior to the commencement of the role, clients with risk issues may not have received volunteer services due to absence of a focused community care management plan with clearly defined boundaries for volunteers. Other interviewees commented on the value of mental health assessment and support in reducing risk of spread of HIV infection.

“Making an assessment of their medication regime I had a client who seemed to be becoming more agitated, high levels of anxiety and paranoia and [the Mental Health Drug and Alcohol CNC] could go in there and within a day or two do an initial assessment and assess that it was a medication problem and that the client was being under medicated. He could feed that back to the [hospital] and have that person reviewed from a medication point of view.”

“The main thing was that there was someone out there doing it with some psychiatric training and experience that could make good assessments, good diagnoses and instigate management plans that you knew were good and appropriate.”

“We often defaulted to the [Mental Health Drug and Alcohol CNC], what is your experience and what do you think can be offered to this client. Then that allowed us to go back to the Chief Health Officer and say look we’ve got somebody in the community who is able to oversee ... and we’re confident that these things are in place which minimises the risk. Because you look after the client’s mental health and you minimise the risk to the public health.”

“It was through the [Mental Health Drug and Alcohol CNC] input in that situation saying well this is what the client needs and yes it is safe to introduce a volunteer provided it is within these parameters. We can then with confidence put a far less trained person into assist because the [Mental Health Drug and Alcohol CNC] has made that assessment as to what is appropriate.”

75

I think [the Mental Health Drug and Alcohol CNC] resulted in a better service for my clients.”


Interviewees reported that there were no limitations as service is needed due to so many clients having mental health issues. Three interviewees commented that there is too much demand for the available service and therefore it should not only be continued but expanded upon to include at least two Mental Health Drug and Alcohol CNC roles. A number of community-based interviewees also noted that their clients would benefit from greater outreach availability of the role and for these arrangements to be formalised. According to one hospital based interviewee, confidentiality arrangements require clarification in order to facilitate greater clinically relevant information sharing with acute mental health services. Additionally, one interviewee commented that rural Victorians would benefit from access to community based mental health drug and alcohol nurses in HIV/AIDS.

“The limitation is time and hours. There’s one person in that position and arguably it’s an area that’s growing in demand and it’s hard for [the Mental Health Drug and Alcohol CNC] to get around to cover as much as really needs to be done. I think that the demand is really growing probably beyond what has been appreciated.”

“Keep it going it is essential. I think for people in community centres like ourselves and with the complexities that HIV now presents with we don’t have the skill set so I think it is essential that this should be kept going to serve the community well.”

“The role should be expanded”

“It’s just been such a positive experience for me and I believe my clients as well. It was a service that we needed.”

76

7 Discussion

7.1 Case and Demographic Data Case and demographic data collected for the entire group of 119 people receiving care on the RDNS HIV/AIDS program over the four month client recruitment period in 2007 indicate that they were male, in their mid 40s, and the majority were born in Australia, reflecting a similar demographic profile as that presented in Chapter 4. Based on agreement or eligibility to participate, three distinct cohorts emerged in this project, with almost equal numbers of clients agreeing to participate as declined. A smaller number did not meet the selection criteria, predominantly due to cognitive impairment or because they were experiencing a crisis at the time of recruitment. It is not known why some people declined to participate in the evaluation as this information was not collected. However anecdotally, recruiters noted that several people declined due to stigma regarding mental health, some believed that they did not have mental health difficulties, and a number of people did not wish to discuss their mental health problems due to their difficulties tolerating unpleasant or distressing emotions. ‘Living arrangement’ and ‘carer availability’ data for the 119 people suggest that they often lived alone with no carer indicating that they are at risk of social isolation, a recognised contributing factor to poor mental health. Importantly, there were no significant differences in the demographics between those who agreed to participate, those who declined and those who were not eligible.

Consistent with the 2006 profile data presented in Chapter 4, over 60% of people in each of the three cohorts had a recorded mental disorder, indicating a high rate of mental health problems, with the highest rate recorded for those who agreed to participate and were assessed. Depression and drug/alcohol use problems were the two most frequently recorded problems amongst people in each of the three cohorts. Anxiety was recorded as the third most frequent mental health problem amongst those who agreed to participate as well as those who declined. It has been suggested in past literature that people with mental health diagnoses are more likely to decline to participate in studies, however, in this evaluation, there were no differences between the three cohorts, indicating that those with a recorded mental disorder were not more likely to decline.

The most frequently recorded nursing activities for these clients were medication management and health monitoring. The issues of mental health, medication management and HIV/AIDS are current research priorities. This is due to the increased risk of HIV infection for people with mental health problems, the strong association between chronic HIV infection and the development of major mental disorders including depression, bipolar disorder and HIV dementia; and difficulties people with mental health problems experience with adherence to complex anti-retroviral medication regimes necessary to combat HIV and minimise its effects (Jeanes, Hill, Wojicki, & Vujovic, 2007). Therefore, improved management of mental health and drug and alcohol problems for people living with HIV/AIDS, through focused and timely mental health assessment and community based interventions including appropriate referrals and liaison with relevant mental health providers, would be expected to improve clients’ mental health and adherence with medication regimes, minimising the incidence and prevalence of major mental disorders in these people or prevent deterioration in existing problems.

7.2 Screening and Referral Data All 43 clients who agreed to participate were screened with the K10 and MMSE. It is of note that over 80% of these people were found to have a potentially clinically significant score of 16 or more on the self-report K10 scale, indicating psychological distress. All people scored above the cut off of 23 or more on the MMSE indicating that they were not demonstrating significant cognitive dysfunction, as was stipulated in the selection criteria.

77

All of these 43 clients were referred to the Mental Health Drug and Alcohol CNC for a comprehensive mental health drug and alcohol nursing assessment including collection of a number of validated and reliable measures of: self-report depression, anxiety and stress (DASS21); structured clinician administered interview capturing drug and alcohol use and associated risk (ASSIST); clinician rated mental health signs, symptoms and dysfunction (HONOS); and self-reported quality of life (WHOQOL bref).

7.3 Nursing Assessment Descriptive data were captured during the nursing assessment including: past and current mental health diagnoses and treatment, and activities undertaken by the Mental Health Drug and Alcohol CNC.

Depression was the most frequently reported past and current mental health diagnosis. Fewer clients reported past or current anxiety. Psychotropic medication was the most frequently reported past and current treatment, with counselling/psychotherapy reported less often. It is of particular concern that although over 80% of people in this sample reported psychological distress above the moderate severity level cut-off score (as captured by the K10), less than half were found to be taking psychotropic medication, and just over a quarter reported currently receiving counselling/psychotherapy. Thus, data captured by the K10 suggest that greater numbers of people are experiencing depression and/or anxiety and would benefit from mental health interventions including psychotropic medication and/or counselling/psychotherapy. These findings suggest that a number of people are experiencing mental health symptoms but are not being identified or treated for these problems.

It is of note that almost no people in this sample reported difficulty with drug and alcohol use, although over a quarter had a substance use problem recorded on the RDNS client database suggesting that these clients underestimate their substance use. Findings indicate that RDNS clients living with HIV/AIDS would benefit from a systematic approach to screening for psychological distress and for substance use in order to identify those with potential or actual mental health drug and alcohol difficulties and refer them to appropriate services. Findings further indicate that people who are receiving treatment from RDNS also may require screening, assessment and referral for review and follow-up of their treatment plan/medication regime to improve their treatment outcomes.

All clients who were referred to the Mental Health Drug and Alcohol CNC underwent a comprehensive and focused mental health and drug and alcohol assessment, review or formulation of care plans, client and carer education, and health promotion in regard to mental health and, where relevant, drug and alcohol use and associated risk. Over 88% of these people had their mental health drug and alcohol risk monitored, numerous referrals were made, and 41 were reviewed 6-8 weeks following their initial assessment. Importantly, a number of authors assert that these activities characterise community nursing practice in Australia with its focus on assessment in the client’s own environment, self-management strategies, liaison with external health providers; psychological support and health promoting education (Keleher, 2007; Talbot & Verrinder, 2005). These findings demonstrate that the Mental Health Drug and Alcohol CNC role varies from other psychiatry focused nursing roles undertaken in inpatient settings, such as consultation liaison psychiatry nursing roles with their focus on the hospitalised patient and tendency to manage acute psychiatric health problems (Sharrock & Happell, 2000, 2001). Instead, this Mental Health Drug and Alcohol CNC role within RDNS emphasised the person’s ability to self-care in their own home, health promotion, and mental health promotion; thereby supporting people living with HIV/AIDS to remain in the community.

7.4 Client Assessment and Follow-up Data Relationships between data from the K10 and assessment measures for all 43 clients were appraised and are presented in the correlation matrix in Table 6.16. It is of interest that the K10 data are highly positively correlated, above 0.7, with all three DASS21 subscales suggesting that the K10 and DASS21 are capturing a similar construct of psychological distress. The Alcohol and Cannabis subscales of the ASSIST are

78

moderately correlated with the behavioural problems subscale of the HONOS indicating that people who are using alcohol and cannabis at risky levels (as defined by the scoring instructions for the ASSIST) are more likely to demonstrate problematic behaviours. The symptoms (physical and psychological) subscale of the HONOS is moderately correlated with the K10 and the three DASS21 subscales suggesting that there is a significant relationship between observed signs and reported psychological symptoms. Interestingly, the four domains of quality of life: physical health, psychological health, social relationships and environment are all moderately to strongly negatively correlated with the K10 and three DASS21 subscales indicating these people experience low levels of quality of life and high levels of psychological distress in particular depression, anxiety and stress.

7.4.1 Depression Anxiety and Stress Scales (DASS21)

At assessment and follow-up, almost two thirds of participants reported depression and anxiety symptoms above the moderate severity cut-off, and almost one half reported stress symptoms above the moderate severity cut-off indicating a considerable number of these people experienced psychological distress. Assessment and follow-up data for moderate symptom severity on all three DASS21 subscales were compared, however; no significant differences were found. Similarly, comparisons of mean scores on these three subscales at assessment and follow-up found no significant differences. These data indicate that there was no change in either mean score or the number of people scoring above the moderate level of symptom severity at assessment and at follow-up.

Assessment and follow-up DASS21 measures were compared as descriptive and exploratory analyses and significant differences were not anticipated. It is of note that peoples’ psychological difficulties did not become worse, although any significant differences could not have been causally related to the Mental Health Drug and Alcohol CNC role due to the absence of a control group in this evaluation design.

7.4.2 Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

In accordance with the criteria provided in the ASSIST manual, scores indicating a moderate level of risk in relation to substance use at assessment and follow-up for the tobacco, alcohol and cannabis subscales were utilised. There were insufficient data to warrant analyses with the remaining ASSIST subscales. Over two thirds of participants reported risky tobacco use, slightly less than one quarter disclosed risky alcohol use and almost one third of participants stated that they used cannabis at risky levels. These assessment and follow-up data were compared and no significant differences were found. Comparisons of mean scores at assessment and follow-up for these three subscales were also compared and no significant change was found.

The absence of change in the ASSIST subscales was expected for reasons outlined above. Additionally, this was not a cohort of people seeking treatment for their substance use problems, indeed a substantial number of these people did not consider themselves to be experiencing substance use difficulties according to data collected in the nursing assessment, therefore improvement in risky substance use behaviours would not be expected. Importantly, findings highlight the high numbers of people in the current sample using substances at a risky level.

7.4.3 Health of the Nations Outcomes Scales (HONOS)

Using criteria provided in the HONOS manual, participants’ scores were coded into those falling above the moderate severity problem rating for each of the four HONOS subscales. A small number of participants were rated at assessment and follow-up as having behavioural problems above the moderate severity cut-off. Approximately one third of people were rated above a moderate level of problem severity on the ‘impairment’ and ‘symptomatic’ subscales at assessment with these numbers reduced to just below one fifth at follow-up. Just over two thirds of people were rated above the moderate level of problem severity at assessment on the ‘social problems’ subscale, with these numbers reducing to just above one third at follow-up. Comparisons of these data found significantly fewer participants above the moderate problem

79

severity cut–off at follow-up on the ‘impairment’ and ‘social problems’ subscales. There were no significant differences on the ‘behavioural problems’ or ‘symptomatic problems’ subscales. Comparisons of mean scores at assessment and follow-up using paired samples t tests were significantly different on the ‘social problems’ subscale indicating improvement in this domain, there were no significant differences found on the remaining three HONOS subscales.

Changes on the ‘impairment’ and ‘social problems’ subscales of the HONOS indicate that peoples’ functioning had improved in these domains at follow-up, although this can not be causally attributed to the Mental Health Drug and Alcohol CNC due to the absence of a control group. The absence of change on the ‘behavioural problems’ and ‘symptomatic problems’ subscales are consistent with the self-report data in relation to the DASS21 subscales of depression, anxiety and stress. On the ‘symptomatic problems’ subscale, the number of people found to be at or above the moderate level of problem severity had reduced by almost half at follow-up, however; this was not significantly different as it was counterbalanced by the four people who were below the cut-off score at assessment and then changed to above the cut-off at follow-up.

7.4.4 Quality of Life (WHOQOL bref)

Importantly, participants’ mean scores on all four quality of life domains are considerably lower than Australian population norms reported in the Australian WHOQOL manual. Mean scores on the physical health and psychological health domains are almost two standard deviations lower, and mean scores on the social relationships and environment domains are just over one standard deviation lower than Australian population normative data. These descriptive data indicate that this group of clients requires considerable support. Comparison of means on all four WHOQOL bref domains at assessment and follow-up using paired samples t tests were not significant, indicating no change. Again the absence of change in these scores may be attributed to the developing nature of the Mental Health Drug and Alcohol role and insufficient time for interventions to be effective.

7.5 Client and Carer Survey Data

7.5.1 Client Surveys

The high response rate of 60% suggests that this client group were interested and committed participants in the project. Importantly, 20 of 25 respondents were satisfied with the Mental Health Drug and Alcohol CNC role with four people endorsing mildly satisfied and one person neutral/unsure. Over 70% of respondents were ‘satisfied’: that the Mental Health Drug and Alcohol CNC role was timely; with the questions asked during assessment; that the nurse listened and was understanding; was competent and knowledgeable; and that their opinions and choices were respected. One person reported ‘mild dissatisfaction’ and one reported being ‘mostly dissatisfied’ in regard to being listened to and understood, and there was one ‘mildly dissatisfied’ response to the question regarding respect by the Mental Health Drug and Alcohol CNC for the respondents’ opinions and choices.

Interestingly, respondents’ endorsement of the ‘satisfied’ response to the items regarding: the amount of help received; dealing more effectively with mental health problems; care options; referral options; and information received, ranges between 44 and 68%, with most of the remaining respondents reporting being ‘mildly satisfied’. The numbers of people reporting being satisfied with these areas of the service are lower than those regarding: overall satisfaction with the service; timeliness; questions asked; being listened to; the nurse’s competency; and that their opinions and choices were respected. This suggests that respondents were well satisfied with the nurse’s interpersonal skills and assessment, and that although most people were at least mildly satisfied, they were not as satisfied in regard to interventions more directly related to psychological symptom management, such as care options and referral options. The effectiveness of referrals from the Mental Health Drug and Alcohol CNC to other providers and services and direct mental health interventions and treatments as provided by medical and allied health practitioners was not the object of the current investigation. However, when these satisfaction survey findings are considered

80

together with the absence of change in psychological symptoms as appraised with the DASS21 assessment and follow-up measures of depression, anxiety and stress they may indicate problems with effective referrals from the Mental Health Drug and Alcohol CNC to other health practitioners. Past evaluation of referral between generalist district nurses and general practitioners regarding mental health difficulties in community dwelling veterans and war widow(er)s found nurses and GPs reported low overall satisfaction with communication processes highlighting difficulties for generalist district nurses and GPs in effectively liaising and referring (Annells et al., 2007).

7.5.2 Carer Surveys

Unfortunately only four carer surveys were returned. All four of these carer respondents reported satisfaction with effectiveness of the Mental Health Drug and Alcohol CNC assisting them to deal with the person’s mental health problems. As noted in Tables 6.4 and 6.5 almost half of the people in this cohort were recorded as not needing a carer and over half lived alone indicating that for approximately half of these people there was no carer. However, reasons for absent responses from potentially available carers are not known.

7.6 Client Interviews The 14 interviews with clients resulted in the following four main themes:


2. Enhanced support



Responses from client interviewees in this random sample are consistent with the client satisfaction survey and assessment and follow-up measures of psychological distress as captured by the DASS21, and functional difficulties as captured by the HONOS. Interview data support that the Mental Health Drug and Alcohol CNC role demonstrated advanced interpersonal skills and caring, thereby providing highly effective support. These outcomes of the role were not captured in the quantitative data and provide additional information regarding the effectiveness of this advanced practice nursing role with a strong foundation in community mental health due to the main themes of support and health promoting education. These qualitative findings may also partially explain improvement in the social problems domain of the HONOS as related to the enhanced support and “being listened to” by the Mental Health Drug and Alcohol CNC as reported in the client interviews. Participants’ comments regarding the main theme of health promoting education are of interest as they emphasise the importance of this domain of the role and its potential for preventing exacerbation of acute mental health crises necessitating referrals to inpatient facilities. Past literature notes the effectiveness of preventative health interventions in reducing hospital admissions and in maintaining people in their own homes in the community (Baum, 2004). Importantly, interviewees all reported that they valued the role and wanted it to continue and to expand.

7.7 Focus Group Interview The focus group interview with RDNS staff resulted in the following five themes:



81




Participants’ comments regarding the first theme, mental health and drug and alcohol problems for RDNS clients living with HIV/AIDS highlights social, behavioural and financial difficulties. They explained how these problems interfere with clients’ ability to adhere to, even commence anti-retroviral medication. This information is consistent with the client profile, case and demographic data and nursing assessment data indicating that over 60% of RDNS clients living with HIV/AIDS experience mental health problems and the most frequent nursing activities for RDNS clients living with HIV/AIDS are focused on assisting them with medication management. Additionally, within this theme, participants described a significant problem with HIV clients in regard to suicide and suicidal ideation. Prior to the commencement of the Mental Health Drug and Alcohol CNC role, generalist RDNS nurses with limited educational preparation in psychiatric nursing have frequently cared for suicidal clients. Focus group participants elaborated further on caring for clients before the commencement of the Mental Health Drug and Alcohol CNC role. They noted that this was difficult for them as psychiatric and drug and alcohol nursing is beyond their scope of practice as generalist nurses and they have received limited support from community mental health and drug and alcohol services. Past literature has noted poor responsiveness of mental health services in Australia, in particular for people who are not severely mentally ill, and the inadequate funding of mental health services by the Australian Government (Hickie, Groom, McGorry, & Davenport, 2005).

Importantly, findings from the focus group identified that the Mental Health Drug and Alcohol CNC role was effective for clients. Participants described this in terms of effective community based mental health drug and alcohol care including: assessment in the community, care management and behaviour management plans focused on keeping the person in the community, advocacy, health promotion, medication management, and prevention of mental ill health and crises. They noted that the role was highly accessible as demonstrated in the highly successful outreach service provided at the Positive Living Centre.

Focus group findings also emphasise that the Mental Health Drug and Alcohol CNC role was collaborative and worked within the nursing team and with the RDNS social workers in care provision. It was an accessible resource, educating RDNS generalist nurses, thereby building the capacity of RDNS clinicians to provide better holistic care to clients. Although the role was focused on mental health and drug and alcohol care for people living with HIV/AIDS, it is expected that education provided to staff will improve their holistic care of other RDNS clients and include a focus on mental health.

Participants considered that the role as trialled was an underestimation of its true potential due to the developmental nature of the role over the 12 month trial, and because data collection requirements inhibited the time available to undertake further education. They considered that the role should be refined to promote benefits to the clients and undertake additional education for RDNS staff.

7.8 Phone Interviews Phone interviews with seven external providers resulted in the following four themes:





82

The phone interview data emphasise that the Mental Health Drug and Alcohol CNC role added value to the community team and collaborated effectively with external service providers. Service providers said that they were able to work together with the Mental Health Drug and Alcohol CNC to provide improved care management to their clients based on focused mental health assessment undertaken in the community agency or in the client’s home. Findings indicate that the Mental Health Drug and Alcohol CNC role provided effective consultation and liaison to these people and worked in partnership. These findings further support the important community focus of this role which was highly accessible, available and collaborative, and distinguish it from other roles described in the literature such as the psychiatric consultation nursing role.

Additionally, phone interview data indicate that the role was effective for clients as it facilitated improved care planning and behavioural management thereby enabling people with significant mental health and drug and alcohol difficulties to access community support services. Importantly, some interviewees considered that the improved behavioural management of the client would minimise the risk of transmission of HIV and therefore the role had potential benefits to public health.

It is of note that phone interview participants considered that there were no limitations to the role, which is consistent with the focus group and client interview data. According to phone interviewees, the Mental Health Drug and Alcohol CNC role should be continued and expanded.

7.9 Limitations There are a number of limitations to the current evaluation project:

1. The current evaluation findings describe the effectiveness of the Mental Health Drug and Alcohol CNC role with a self-selected sample of RDNS clients, and a convenience sample of internal and external clinicians. These findings may not therefore generalise to other contexts of community based nursing care.

2. The evaluation of the Mental Health Drug and Alcohol CNC role was not an evaluation of the role in true clinical practice and therefore may under-estimate the effectiveness of this role. This is due to:

− The evaluation of the role occurring concurrently with its development

− The ethical requirement to obtain informed written consent from participants to participate in the project which would not be required in routine RDNS practice as written consent to receive the service is undertaken on admission to RDNS

− The evaluation included more extensive data collection than would be undertaken in routine clinical nursing practice at RDNS.

3. Although people with cognitive impairment and those experiencing health crises accessed the Mental Health Drug and Alcohol CNC for clinical care during the project, they were excluded from the evaluation due to difficulty obtaining informed consent or because they did not meet the selection criteria. Although no significant differences were found between these clients and the participants when compared on their demographic characteristics, it can not be guaranteed that the current findings from clients including: screening, assessment, and follow-up data; client satisfaction survey data; and client interview data; will generalise to those people who did not meet the selection criteria.

4. The absence of studies in mental health and drug and alcohol nursing roles in community care contexts resulted in limited ‘pre’ work available in the published literature which could guide the current trial and development of the Mental Health Drug and Alcohol CNC role.

83

5. The absence of a control group precludes attribution of any changes in quantitative measures to the Mental Health Drug and Alcohol CNC role.

84

8 Conclusion There is a clear need for RDNS clients living with HIV/AIDS to receive focused mental health and drug and alcohol assessment and care. Findings from the client profile and evaluation reveal that over 60% of RDNS HIV/AIDS clients have mental health and/or drug and alcohol problems. This client group experiences considerable psychological distress, problematic use of substances, and a substantially lower quality of life than most Australians indicating that they would benefit from additional mental health support, namely, continued development of the Mental Health Drug and Alcohol Clinical Nurse Consultant role with the HIV/AIDS Team.

Importantly, evaluation findings in regard to client outcomes, as appraised from the client satisfaction survey and interview data, suggest that the Mental Health Drug and Alcohol CNC role provided an accessible, available and valuable service. Respondents reported that the role provided them with vital mental health support. Additionally, clients reported strong satisfaction with this nursing role.

Findings regarding clients’ psychological distress, drug and alcohol risk, functioning and quality of life, as appraised with the valid and reliable measures collected at assessment and 6-8 week follow up, did not reveal many significant differences, with the exception of the ‘impairment’ and ‘social problems’ domains of the HONOS which had improved at follow-up. Importantly, these findings did not indicate deterioration in these symptom and behavioural areas, although changes could not be causally attributed to the Mental Health Drug and Alcohol CNC role due to the absence of a control group. The client assessment and follow-up findings are consistent with client survey data which found that although clients reported satisfaction with the Mental Health Drug and Alcohol CNC role, lower levels of satisfaction were reported for the referral and care options survey items. Several factors may explain these findings. There may have been insufficient time to capture any changes. Additionally, evaluation data described the Mental Health Drug and Alcohol CNC role as focused on community based care: assessment in the home, support, access to services such as acute mental health services, referral, health education, health promotion and prevention of mental ill health and crises. Thus the ‘intervention’ did not directly ‘treat’ symptoms or problematic behaviours, but referred to other providers to do so and the effectiveness of referrals and/or direct mental health interventions and response by other health practitioners was not able to be directly influenced by RDNS and nor was this part of the current evaluation. These issues require further investigation in future studies.

RDNS nurses and social workers participating in the focus group interview and externally based health providers participating in phone interviews reported highly effective collaboration with the Mental Health Drug and Alcohol CNC. These findings indicate that the role worked in partnership to enhance assessment and care plans for clients and to provide shared care to affected people, increasing their access to services. In particular, the outreach service at the Positive Living Centre was considered to be a highly valuable component of the role as it enhanced access and availability for both clients and for staff.

Importantly, evaluation findings suggest that the Mental Health Drug and Alcohol CNC role was a community based nursing role operating within the primary care principles of partnership with clients and other health providers, and access to and availability of health services. Given the absence of published literature regarding this role in community nursing contexts, this developmental project is pioneering work as the role was developed largely de novo within a well established and unique team of community based Clinical Nurse Consultants in HIV/AIDS nursing care.

Findings strongly support continuation of the Mental Health Drug and Alcohol CNC role. Evaluation findings further indicate that future government health policy in HIV/AIDS should include additional community-based mental health, drug and alcohol nursing care and support for these highly vulnerable people.

85

9 Recommendations

In view of the evaluation findings, the following recommendations are made:

1 That the Mental Health Drug and Alcohol Clinical Nurse Consultant role be established as a permanent element of the RDNS HIV team

The findings of the evaluation and the client profile data indicate that over 60% of RDNS clients living with HIV/AIDS experience co-morbid mental health and/or drug and alcohol problems. Over half of them are living alone and have no carer, which increases their risk of social isolation and further predisposes them to poor mental health. People living with HIV/AIDS are living longer, and are therefore more likely to develop major mental disorders as a direct result of the effects of the virus on the central nervous system, including HIV dementia and bipolar disorder. Furthermore, a significant proportion of clients with HIV also have Hepatitis C co-infection and are undergoing treatment for their Hepatitis C, which can result in severe neuro-psychiatric side-effects. In the future, RDNS is likely to receive increasing numbers of referrals for Hepatitis C treatment and support. Therefore, it is anticipated that the already substantial mental health needs of this client group, will continue to increase. Additionally, RDNS clients living with HIV/AIDS report high levels of psychological distress, substance use difficulties and a quality of life significantly below that of their Australian counterparts. This group of people have complex needs which requires specialist expertise to effectively manage, such as that provided by the Mental Health Drug and Alcohol Clinical Nurse Consultant role. In view of the increased demand for mental health drug and alcohol care for this client group, it is recommended that the Victorian Department of Human Services provide recurrent funding to enable the establishment of the Mental Health Drug and Alcohol Clinical Nurse Consultant role as a permanent element of the RDNS HIV Team.

2 That the Mental Health Drug and Alcohol Clinical Nurse Consultant role be further developed and expanded

The Mental Health Drug and Alcohol CNC role was found to be highly congruent with that of the existing team of HIV/AIDS Clinical Nurse Consultants and within RDNS. Evaluation findings indicate that the role effectively supported clients to remain in the community and effectively supported management of their social and mental health crises. Moreover, health professionals within RDNS and external to the agency found the role highly collaborative, accessible and available. Throughout the course of the project, the following improvements to the role were also suggested:

− The outreach service at the Positive Living Centre (PLC) should be continued and these arrangements should be formalised between the Victorian AIDS Council (VAC) and RDNS

− Additional outreach services in other regions within the greater Melbourne metropolitan area should be considered

− Linkages between the Mental Health Drug and Alcohol CNC role and mental health and drug and alcohol services should be further developed

− Improved access to direct mental health interventions for RDNS clients living with HIV/AIDS should be considered, including supportive counselling.

86

3 That the service delivery components of the Mental Health Drug and Alcohol CNC role be modified

Referrals should continue to be made to the Mental Health Drug and Alcohol CNC via the RDNS HIV/AIDS Clinical Nurse Consultants and this should be expanded to include the HIV Resource Nurses. Where relevant, nurses referring people to the Mental Health Drug and Alcohol CNC should use the RDNS Mental Health Screening and Referral Clinical Pathway, which includes the K10 and Alcohol Use Disorder Identification Test (AUDIT) as screening tools, to facilitate their identification of people with actual or potential mental health and/or drug and alcohol problems, and clinical decision making. Referrals from external providers including the Victorian AIDS Council, and the Alfred, Royal Melbourne, St Vincent’s and other public hospitals should be encouraged and continue to develop. Assessment systems including valid and reliable tools used in the evaluation should be modified for future clinical practice to streamline or simplify documentation requirements. It is recommended that future assessment systems include a modified version of the Mental Health Nursing Assessment and the ASSIST.

4 That RDNS develops mental health and drug and alcohol activity codes for inclusion in the client database

Ongoing appraisal of mental health and drug and alcohol focused nursing activities as provided by the Mental Health Drug and Alcohol CNC is warranted in order to describe this new service. These data are important information for those funding RDNS, including government, and in order to monitor future health care needs, and consider improvements to the role. It is recommended that these codes be developed in consultation with the relevant clinicians.

5 That the education components of the Mental Health Drug and Alcohol CNC role be expanded

Evaluation findings identified that the education provided by the Mental Health Drug and Alcohol CNC role was highly effective for clients, RDNS nurses and external service providers including volunteer groups at the Victorian AIDS Council. Additionally, evaluation findings indicate that further development of the education component/s of the role are warranted. Findings indicate that additional education in mental health, drug and alcohol and behaviour management could be provided to RDNS staff across the agency. This would build capacity within RDNS to provide ongoing quality care to this client group. Moreover, additional education sessions with this focus could be provided to external services such as volunteer and community support services in HIV/AIDS and integrated into existing education programmes provided by the RDNS HIV Clinical Nurse Consultants.

87

6 That resources are provided to enable additional investigations to be undertaken to evaluate the impact of the RDNS Mental Health Drug and Alcohol CNC on long-term client outcomes and to appraise the effect of the role on referral systems and care options with external mental health and drug and alcohol services, and with organisations and services catering for clients from culturally and linguistically diverse bacgrounds

Time and resourcing constraints in the current project only allowed short-term follow-up of clients. As measurable changes in psychological functioning and quality of life are unlikely to occur within a short time frame, the provision of additional funding to conduct a 6 to 12 month follow-up of the cohort recruited in this study would be extremely valuable. In addition, the effectiveness of referral systems between the Mental Health Drug and Alcohol CNC and external service providers and care options were not investigated in detail within the current evaluation. Further development, trials and evaluation of referral systems are warranted in this important area of mental health to identify barriers and strategies/systems to enhance access to effective mental health care. The same is required in relation to the identification of barriers and systems to improve access to effective drug and alcohol services. Depression was the most frequently recorded difficulty experienced by these clients and the extensive literature regarding depression indicates that highly effective treatments are available including psychotropic medication and psychotherapy such as cognitive behavioural therapy. Improved access to and uptake of treatments for depression could make a vast difference to the quality of life of RDNS clients living with HIV.

88

References Andrew, G., & Slade, T. (2001). Interpreting scores on the Kessler Psychological Distress Scale. Australian

and New Zealand Journal of Public Health, 25, 494-497.

Annells, A., Allen, J., Nunn, R., Lang, L., Petrie, E., Clark, E., et al. (2007). Development of a Best Practice Mental Health Screening and Referral Pathway for Community Nursing Care of Veterans and War Widow(er)s. Melbourne, Australia: La Trobe University, Bundoora, Australia.

Baum, F. (2002). The new public health: An Australian perspective (2nd ed.). South Melbourne, Australia: Oxford University Press.

Besner, J. (2004). Nurses' role in advancing primary health care: A call to action. Primary Health Care Research and Development, 5, 351-358.

Brendon, S., & Reet, M. (2000). Establishing a mental health liaison nurse service: Lessons for the future. Nursing Standard, 14, 43-47.

Cabassi, J. (1999). Barriers to access and effective use of anti-discrimination remedies for people living with HIV and HCV. A Report Commissioned for the Commonwealth Attorney General's Department. Sydney: Australian National Council on AIDS and Related Diseases Legal Working Party.

Callaghan, P., Eales, S., Coats, T., Bowers, L., & Bunker, J. (2002). Patient feedback on liaison mental health care in Accident and Emergency. Nursing Times, 98, 34-36.

Folstein, M., Folstein, S., & McHugh, P. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.

Happell, B., & Taylor, C. (1999). "We may be different but we are still nurses": An exploratory study of drug and alcohol nurses in Australia. Issues in Mental Health Nursing, 20, 19-32.

Harmon, K., Carr, V., & Lewin, T. (2000). Comparison of integrated and consultation-liaison models for providing mental health care in general practice in New South Wales, Australia. Journal of Advanced Nursing, 32, 1459-1466.

Henry-Edwards, S., Humeniuk, R., Ali, R., Poznyak, V., & Montiero, M. (2003). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Guidelines for Use in Primary Care (Draft Version 1.1 for Field Testing). Geneva: World Health Organisation.

Hickie, I., Groom, G., McGorry, P., & Davenport, T., G. (2005). Australian mental health reform: Time for real outcomes. Medical Journal of Australia, 182, 401-406.

Hillman, A., McCann, B., & Walker, N. (2001). Specialist alcohol liaison services in general hospitals improve engagement in alcohol rehabilitation and treatment outcome. Health Bulletin, 59, 420-423.

Jeanes, M., Hill, C., Wojicki, T., & Vujovic, O. (2007). HIV and Psychiatric Illness. Paper presented at the World Psychiatry Association, Melbourne, Australia.

Keleher, H. (2007). Chapter 2 Social Perspectives on Health. In W. St John & H. Keleher (Eds.), Community Nursing Practice: Theory, Skills and Issues. Crows Nest, NSW, Australia: Allen & Unwin.

Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L. T., et al. (2002). Short screening scales to monitor population prevalences and trends in nonspecific psychological distress. Psychological Medicine, 32(6), 959-976.

Lindsay, F., & McDermott, F. (2000). Dual Diagnosis of Mental Illness and Substance Use Disorder - A Review of Recent Literature. Fitzroy, Australia: Psychiatric Disability Services of Victoria.

Lovibond, S., & Lovibond, P. (2004). Manual for the Depression Anxiety Stress Scales (2nd ed.). Sydney, Australia: School of Psychology University of New South Wales.

89

Minarik, P., & Neese, J. (2002). Essential educational content for advanced practice in psychiatric consultation liaison nursing. Archives of Psychiatric Nursing, 16, 3-15.

Murphy, B., Herrman, H., Hawthorne, G., Pinzone, T., & Evert, H. (2000). Australian WHOQOL Instruments: User's Manual and Interpretation Guide. Melbourne, Australia: Australian WHOQOL Field Study Centre.

Nkowane, A., & Saxena, S. (2004). Opportunities for an improved role for nurses in psychoactive substance use: Review of the literature. International Journal of Nursing Practice, 10, 102-110.

Norwood, S. (1998). Psychiatric consultation-liaison nursing: Revisiting the role. Clinical Nurse Specialist, 12, 153-156.

Nunn, R., & Allen, J. (2006). RDNS Model of Mental Health Care Final Report. Melbourne, Australia: Royal District Nursing Service.

Pallant, J. (2002). SPSS Survival Manual. Sydney: Allen & Unwin.

Paterson, D., L, Swindells, S., Mohr, J., Brester, M., Vergis, E., Squier, C., et al. (2000). Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of International Medicine, 133, 21-30.

Priami, M., & Plati, C. (1997). The effectiveness of the mental health nursing interventions in a general hospital. Scandinavian Journal of Caring Sciences, 11, 56-62.

Richardson, C. (2003). Dual Diagnosis: A Basic Understanding. Box Hill, Australia: Eastern Health Dual Diagnosis Team, Box Hill Hospital.

Roberts, D. (1997). Liaison mental health nursing: Origins, definiton and prospects. Journal of Advanced Nursing, 25, 101-108.

Royal District Nursing Service. (1997). The Royal District Nursing Service HIV/AIDS Team Care Manual. Melbourne, Australia: Author.

Royal District Nursing Service. (2007). Annual Report. Melbourne, Australia: Author.

Sharrock, J., Grigg, M., Happell, B., Keeble-Devlin, B., & Jennings, S. (2006). The mental health nurse: A valuable addition to the consultation-liaison team. International Journal of Mental Health Nursing, 15, 35-43.

Sharrock, J., & Happell, B. (2000). The role of the psychiatric consultation-liaison nurse in the general hospital. Australian Journal of Advanced Nursing, 18, 34-39.

Sharrock, J., & Happell, B. (2001). An overview of the role and functions of a psychiatric consultation liaison nurse: An Australian perspective. Journal of Psychiatric and Mental Health Nursing, 8, 411-417.

Sharrock, J., & Happell, B. (2002). The psychiatric consultation-liaison nurse: Thriving in a general hospital setting. International Journal of Mental Health Nursing, 11, 24-33.

Talbot, L., & Verrinder, G. (2005). Promoting health: Health care approach (3rd ed.). Sydney, Australia: Elsevier/Churchill Livingstone.

Tilley, S., & Chambers, M. (2006). Perceived facilitators and barriers to the implementation of an advanced practice nursing intervention for HIV regimen adherence among the seriously mentally ill. Journal of Psychiatric and Mental Health Nursing, 13, 626-628.

Wand, T. (2004). Mental health liaison nursing in the emergency department: On-site expertise and enhanced coordination of care. Australian Journal of Advanced Nursing, 22, 25-31.

Wand, T., & Happell, B. (2001). The mental health nurse: Contributing to outcomes for patients in the emergency department. Accident and Emergency Nursing, 9, 166-176.

90

Wing, J., Beevor, A., Curtis, R., Park, S., Hadden, S., & Burns, A. (1998). Health of the Nation Outcome Scales (HONOS). British Journal of Psychiatry, 172, 11-18.

91

Appendices

Appendix A – MMSE

92

94

Appendix B – Client Cognitive Capacity Checklist

CAN THE CLIENT PROVIDE HIS/HER OWN CONSENT?

Please tick ‘yes’ or ‘no’ to each statement based on your knowledge of the client:

The client would be able to understand what the project is about when it is explained to him/her?

Yes No

The client would know that it is up to him/her only to decide to be in the project?

Yes No

The client would understand what benefit s/he might have from being in the project?

Yes No

The client would understand the risks and inconvenience involved in being in the project?

Yes No

The client would understand that s/he can complain about the project to any one of the following people: a member of the Project Team or the Chair of the RDNS Research Ethics Committee?

Yes No

If you answered ‘no’ to any of these or are uncertain about any of these, use the Consent Form – ‘on behalf of the client’ signed by their carer who may act as the Person Responsible.

The person responsible is a person meeting one or more of the following criteria:

• An agent – appointed by the patient under enduring power of attorney (medical treatment) • A person – appointed by VCAT to make decisions about the proposed treatment • A guardian – appointed by VCAT to make decisions about the proposed treatment • An enduring guardian – appointed by the patient with health care powers • A person – appointed by the patient in writing to make decisions about medical and dental

treatment including the proposed treatment • The patient’s spouse or domestic partner • The patient’s primary carer, … excluding paid carers, service providers or volunteers • The patient’s nearest relative over the age of 18.

(Guardianship and Administration Act – the law on medical research procedures involving adult patients under a legal incapacity - July 2006 and Office of the Public Advocate, 2006)



Appendix C – Plain Language Statement (Client)

Supporting the Mental Health Needs of People Living with HIV/AIDS in a District Nursing Environment.

Plain Language Statement – Information Letter for Clients Project Team:

Russell Nunn Researcher, Research and Development Department, RDNS Helen Macpherson Smith Institute of Community Health

Liz Crock HIV/AIDS Clinical Nurse Consultant, RDNS Yarra Centre Adam Hamilton Mental Health Clinical Nurse Consultant, RDNS Yarra Centre Maureen Wilkinson Centre Manager, RDNS Altona Centre Barbara Williams Mental Health Clinical Nurse Consultant, RDNS Essendon Centre Jacqui Allen Project Officer What is the project about? Royal District Nursing Service (RDNS) is conducting this evaluation project to better understand how people living with HIV/AIDS can be helped with mental health and drug and alcohol problems. The aim of this project is to develop and test a Mental Health Clinical Nurse Consultant role for RDNS HIV/AIDS clients. Funding for this new program and its evaluation is provided by the Victorian Department of Human Services. This letter tells you about the project. Please read this letter carefully and contact Jacqui Allen, the Project Officer, if you have any questions on 9536 5335 or on email at [email protected]. Your consent: If you agree to participate, you will be part of the project during some time between March and October 2007. Your RDNS nurse will ask you some questions about what your mental health needs may be. This may be all that you will be asked to do. You may also be referred to the Mental Health Clinical Nurse Consultant for the HIV/AIDS Team who will:

• Visit you at home and talk with you in more detail about any mental health concerns that you may have • Consider available care and service options together with you and your carer • With your permission, may talk to your doctor or other health professional about your treatment needs • Ask you some questions about your quality of life • Towards the end of the project, will visit you and repeat the questions about your mental health and

quality of life • Towards the end of the project, invite you to complete a questionnaire, expected to take 20 minutes,

about how satisfied you were with the nursing care, support provided and process of referral to other services.

• Towards the end of the project, give you a questionnaire for your carer to complete about how satisfied they were with the nursing care, support provided and process of referral to other services

• May invite you to participate in a face-to-face interview with a member of the Project Team, to ask you about your viewpoint regarding the quality of nursing care in relation to meeting your health needs, support provided and process of referral to other services. This interview would be conducted in a place and at a time convenient to you and would be expected to take 30 minutes. With your permission, the interview would be audio-taped.

• All of the information collected about you will include your RDNS client number (but not your name) in order to match up all of your information. If you agree to take part in the project, you will be asked to sign a consent form. By signing the consent form you indicate that you understand this information and that you give your consent to participate in the project.

95

mailto:[email protected]

96

You can say ‘yes’ or ‘no’ to this invitation to participate in this project. If you decide to say ‘no’, this will not affect any of the nursing care that you currently receive from RDNS nurses. If you decide to say ‘yes’, you will continue to get your usual care and you will get some extra care regarding any possible mental health concerns that you may have. If you say ‘yes’ now and later decide that you do not want to participate, you can change your mind and tell the Project Officer (contact details are listed above) at any time up to four weeks after your involvement with the project has ended. What are the possible benefits and risks? This program may bring benefit to you in the form of quality nursing care for your mental health as well as your physical needs. We cannot advise you that participating in the evaluation, will provide direct benefit to you. However; it will be of general benefit in the longer term and it is not likely that you will experience any risks or discomfort from this process. How will my personal information be used? A report will be written, and journal articles and conference papers may be written. These will include information reported for the entire group of clients and, with your permission, your health care story may be written up as a case study. You will remain anonymous in all of these reports and you will not be identifiable in any report or case study. How will my personal information be kept confidential, private and secure? All information you provide to us will be treated as strictly confidential. Your name or identifying details will not be presented on any reports or case studies. Names or incidents that make identification possible will not be included in any material available to anyone outside the Project Team. During the project, all information collected from you will be kept securely in a locked filing cabinet, and/or on password-protected secure computer files at the RDNS Helen Macpherson Smith Institute of Community Health. After the project is completed, all information would be kept for five years in the archive at the RDNS Helen Macpherson Smith Institute of Community Health. Following five years, all information would be destroyed. Only the Project Team have access to the project information. If you have any concerns the Project Team are not able to answer or complaints about the conduct of this project please contact: Mr Mark Smith Chair RDNS Research Ethics Committee RDNS Helen Macpherson Smith Institute of Community Health, 31 Alma Road St. Kilda, Victoria, 3182 Phone (03) 9536 5382, Fax (03) 9536 5300 Email [email protected]

97

Appendix D – Consent Form (Clients)


Consent Form – Clients

I (insert your name in capital letters)

of (insert your address in capital letters)

hereby consent to participate in the above project.

The details of this project have been explained to me verbally, and I have received a copy of the Plain Language Statement, and Any questions I have asked in regard to this project have been answered to my satisfaction, I understand that any information I provide will be treated with the strictest confidence.

I agree to participate in this project and understand that I may withdraw at any time without my care being affected in any way. If I withdraw from the project up to four weeks after my involvement with the project has ended, any data previously collected about me will be destroyed if I request that this occurs. I agree that data provided by me may be used in a report, presented at conferences or published in journals on the condition that neither my name nor any other identifying information is used. Signature of participant

(Print name) (Signature) (Date)

Witnessed by


98

Appendix E – Consent Form (on behalf of the client)


– ‘on behalf of the client’


of (insert your address in capital letters

hereby consent to participate in the above project in my role as the person responsible on behalf of:

(insert client’s name in capital letters)

of (insert client’s address in capital letters)

The details of this project have been explained to me and the client verbally, and

We have received a copy of the Plain Language Statement, and

Any questions I/we have asked in regard to this project have been answered to my satisfaction,

I understand that any information I/we provide will be treated with the strictest confidence.

I agree on behalf of the client (as listed above) that the client will participate in this project. I understand that I may withdraw on behalf of the client (listed above) at any time without the client’s care being affected in any way. If I withdraw from the project up to four weeks after the client’s involvement with the project has ended, any data previously collected about the client will be destroyed if I request that this occurs. I agree that data provided by me and the client may be used in a report, presented at conferences or published in journals on the condition that neither my name/the client’s name nor any other identifying information is used.

Signature of the person responsible on behalf of the client


Witnessed by


99

Appendix F – K10

K10 ( K e s s l e r , 2 0 0 2 )

Please read each statement and circle a number 1, 2, 3, 4 or 5 which indicates how much the statement applied to you over the past 4 weeks. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

Sca le Problem Score

1 In the past 4 weeks, about how often did you feel tired out for no good reason?

1 2 3 4 5

2 In the past 4 weeks, about how often did you feel nervous?

1 2 3 4 5

3 In the past 4 weeks, about how often did you feel so nervous that nothing could calm you down?

1 2 3 4 5

4 In the past 4 weeks, about how often did you feel hopeless?

1 2 3 4 5

5 In the past 4 weeks, about how often did you feel restless or fidgety?

1 2 3 4 5

6 In the past 4 weeks, about how often did you feel so restless you could not sit still?

1 2 3 4 5

7 In the past 4 weeks, about how often did you feel depressed?

1 2 3 4 5

8 In the past 4 weeks, about how often did you feel that everything was an effort?

1 2 3 4 5

9 In the past 4 weeks, about how often did you feel so sad that nothing could cheer you up?

1 2 3 4 5

10 In the past 4 weeks, about how often did you feel worthless?

1 2 3 4 5

Tota l Score =

100

Appendix G – DASS21

DAS S 21 Name: Date:

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 Did not apply to me at all

1 Applied to me to some degree, or some of the time

2 Applied to me to a considerable degree, or a good part of time

3 Applied to me very much, or most of the time 1 I found it hard to wind down 0 1 2 3

2 I was aware of dryness of my mouth 0 1 2 3

3 I couldn't seem to experience any positive feeling at all 0 1 2 3

4 I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)

0 1 2 3

5 I found it difficult to work up the initiative to do things 0 1 2 3

6 I tended to over-react to situations 0 1 2 3

7 I experienced trembling (eg, in the hands) 0 1 2 3

8 I felt that I was using a lot of nervous energy 0 1 2 3

9 I was worried about situations in which I might panic and make a fool of myself

0 1 2 3

10 I felt that I had nothing to look forward to 0 1 2 3

11 I found myself getting agitated 0 1 2 3

12 I found it difficult to relax 0 1 2 3

13 I felt down-hearted and blue 0 1 2 3

14 I was intolerant of anything that kept me from getting on with what I was doing

0 1 2 3

15 I felt I was close to panic 0 1 2 3

16 I was unable to become enthusiastic about anything 0 1 2 3

17 I felt I wasn't worth much as a person 0 1 2 3

18 I felt that I was rather touchy 0 1 2 3

19 I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)

0 1 2 3

20 I felt scared without any good reason 0 1 2 3

21 I felt that life was meaningless 0 1 2 3

Appendix H – ASSIST

101

113

Appendix I – HONOS

Health of the Nation Outcome Scales (Wing, Curtis, & Beevor, 1996)

(To be rated by the Mental Health Drug and Alcohol CNC)

0 1 2 3 4

Behavioural disturbance

Non-accidental self-injury

Problem drinking or drug-use

Cognitive problems

Physical illness or disability problems

Problems with hallucinations and delusions

Problems with depressive symptoms

Other mental and behavioural problems

(specify disorder A, B, C, D, E, F, G, H, I or J)

Problems with relationships

Problems with activities of daily living

Problems with living conditions

Problems with work and leisure activities

Key for Item 8 A Phobias – including fear of leaving home, crowds, public places, travelling, social phobias and specific phobias B Anxiety and panics C Obsessional and compulsive problems D Reactions to severely stressful events and traumas E Dissociative ('conversion') problems F Somatisation – persisting physical complaints in spite of full investigation and reassurance that no disease is present G Problems with appetite, over- or under-eating H Sleep problems I Sexual problems J Problems not specified elsewhere including expansive or elated mood.

Appendix J – WHOQoL-BREF

WORLD HEALTH ORGANISATION

QUALITY OF LIFE

WHOQoL-BREF

Australian Version (May 2000)

Instructions

This assessment asks how you feel about your quality of life, health, & other areas of your life. Please answer all the questions. If unsure about which response to give to a question, please choose the one that appears most appropriate. This can often be your first response.

Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the last two weeks

Example:

Not at all Slightly Moderately Very Completely

Do you get the kind of support from others that you need?

1 2 3 4 5

You would circle the number 4 if in the last two weeks you got a great deal of support from others

Not at all Slightly Moderately Very Completely

Do you get the kind of support from others that you need?

1 2 3 4 5

but if you did not get any of the support from others that you needed in the last two weeks you would circle 1.

Please read each question and assess your feelings, for the last two weeks, and circle the number on the scale for each question that gives the best answer for you.

114

115

Very poor

Poor

Neither Poor nor Good

Good

Very Good

How would you rate your quality of life? 1 2 3 4 5

Very Dissatisfied

Fairly Dissatisfied

Neither Satisfied nor Dissatisfied

Satisfied

Very Satisfied

How satisfied are you with your health? 1 2 3 4 5

The following questions ask about how much you have experienced certain things in the last two weeks.

Not at all

A Small amount

A Moderate amount

A great deal An Extreme amount

To what extent do you feel that physical pain prevents you from doing what you need to do? 1 2 3 4 5

How much do you need any medical treatment to function in your daily life? 1 2 3 4 5

How much do you enjoy life? 1 2 3 4 5

To what extent do you feel your life to be meaningful? 1 2 3 4 5 Not at all Slightly Moderately Very Extremely

How well are you able to concentrate? 1 2 3 4 5

How safe do you feel in your daily life? 1 2 3 4 5

How healthy is your physical environment? 1 2 3 4 5

Not at all

Slightly

Somewhat

To a great extent

Completely

Do you have enough energy for every day life? 1 2 3 4 5

Are you able to accept your bodily appearance? 1 2 3 4 5

Have you enough money to meet your needs? 1 2 3 4 5

How available to you is the information you need in your daily life? 1 2 3 4 5

To what extent do you have the opportunity for leisure activities? 1 2 3 4 5

Not at all Slightly Moderately Very Extremely

How well are you able to get around physically? 1 2 3 4 5

The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the last two weeks.

Very Dissatisfied

Fairly Dissatisfied

Neither Satisfied nor Dissatisfied

Satisfied

Very Satisfied

How satisfied are you with your sleep? 1 2 3 4 5

How satisfied are you with your ability to perform your daily living activities? 1 2 3 4 5

How satisfied are you with your capacity for work? 1 2 3 4 5 How satisfied are you with yourself? 1 2 3 4 5

How satisfied are you with your personal relationships? 1 2 3 4 5 How satisfied are you with your sex life? 1 2 3 4 5

How satisfied are you with the support you get from your friends? 1 2 3 4 5

How satisfied are you with the conditions of your living place? 1 2 3 4 5

How satisfied are you with your access to health services? 1 2 3 4 5

How satisfied are you with your transport? 1 2 3 4 5

Never Infrequently Sometimes Frequently Always

How often do you have negative feelings such as blue mood, despair, anxiety, depression? 1 2 3 4 5

THE END

116

Appendix K – Satisfaction Survey (Clients)


Survey – Clients

Please return the completed questionnaire within one week by forwarding it in the reply paid envelope by (insert date)

Please place a tick in the appropriate box (only one box) and write comments in the spaces provided

1. Overall, how satisfied are you with the quality of the Mental Health Clinical Nurse Consultant service?

Satisfied 1

Mostly Satisfied 2

Mildly Dissatisfied 3

Mostly Dissatisfied 4

Neutral/Unsure 5

2. How satisfied are you that the Mental Health Clinical Nurse Consultant visits were timely?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

3. How satisfied are you with the questions asked by the Mental Health Clinical Nurse Consultant

at the beginning of care?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

117

4. How satisfied are you that the Mental Health Clinical Nurse Consultant listened to you and understood your problem?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

5. How satisfied are you that the Mental Health Clinical Nurse Consultant was competent and

knowledgeable?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

6. How satisfied are you that your opinions and choices were respected by the Mental Health

Clinical Nurse Consultant?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

7. How satisfied are you with the amount of help you received from the Mental Health Clinical

Nurse Consultant?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

118

8. How satisfied are you that the Mental Health Clinical Nurse Consultant helped you to deal more effectively with any mental health problems?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

9. How satisfied are you with the care options you received from the Mental Health Clinical Nurse

Consultant?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

10. How satisfied are you with the referral options you received from the Mental Health Clinical

Nurse Consultant?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

11. How satisfied are you with the information you received from the Mental Health Clinical Nurse

Consultant?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

119

12. How satisfied are you that the care you received from the Mental Health Clinical Nurse Consultant met your expectations?

Satisfied 1

Mostly Satisfied 2



Neutral/Unsure 5

13. What was the best thing about the Mental Health Clinical Nurse Consultant service?

14. What could have been better?

Thank you for your time

120

Appendix L – Interview Guidelines (Clients & Carers)

The following questions will guide the face-to-face interview. As the interviews are semi structured, additional questions based on answers may be asked and relevant tangents explored.

1. What was the effect of the RDNS Mental Health Nurse on your health and quality of life?

Enhanced support

Health complications

Unplanned visits to hospital

Physical well-being

Symptom relief

Social well-being and day to day life

Education/understanding of your health

Unexpected outcomes

2. What do you value most about the service you received?

3. How do you think that your health and well being would have been different without the RDNS Mental Health nurse?

4. Have you had any negative experiences about the RDNS Mental Health nurse that you would like to discuss?

If so, what were they?

What were the implications of these for you

How could this be avoided in future?

5. What could have been better in regards to the service you received from the RDNS Mental Health nurse?

121

Appendix M – Plain Language Statement (Staff Focus Group)


Information Letter for Focus Group Project Team:


Liz Crock HIV/AIDS Clinical Nurse Consultant, RDNS Yarra Centre Adam Hamilton Mental Health Clinical Nurse Consultant, RDNS Yarra Centre Maureen Wilkinson Centre Manager, RDNS Altona Centre Barbara Williams Mental Health Clinical Nurse Consultant, RDNS Essendon Centre Jacqui Allen Project Officer What is the project about? Royal District Nursing Service (RDNS) is conducting this project to better understand how HIV/AIDS clients can be helped with mental health and drug and alcohol problems. The aim of this project is to develop and test a Mental Health Clinical Nurse Consultant role for RDNS HIV/AIDS clients. The Victorian Department of Human Services is funding the project. This letter tells you about the project. Please read this letter carefully and contact Jacqui Allen, the Project Officer, if you have any questions on 9536 5335 or on email at [email protected]. Your consent: If you agree to participate, you will be part of the project sometime during September to October 2007. You will be invited to participate in a confidential one hour focus group interview during work time. During this focus group, you will be asked about your experiences and ideas regarding the Mental Health Clinical Nurse Consultant role on the HIV/AIDS Team. With your permission, the interview will be audio-taped. If you agree to take part in the project, you will be asked to sign a consent form. By signing the consent form you indicate that you understand this information and that you give your consent to participate in the project. Participation is voluntary. If you decide to say ‘no’, this will not affect your employment with RDNS in any way. If you say ‘yes’ now and later decide that you do not want to participate, you can change your mind and tell the Project Officer (contact details are listed above). What are the possible benefits and risks? We cannot advise you that you will directly benefit from this project but you may do so as you would be helping with a project that should help RDNS HIV/AIDS clients in future. It is not likely that you will experience any risks or discomfort from taking part in this project. How will my personal information be used? A report will be written, and journal articles and conference papers may be written. These will include information reported for the entire group of nurses. You will remain anonymous in all of these reports and you will not be identifiable in any report. How will my personal information be kept confidential, private and secure? All information you provide to us will be treated as strictly confidential. Your name or identifying details will not be presented on any reports or case studies. Names or incidents that make

122


identification possible will not be included in any material available to anyone outside the Project Team. During the project, all information collected from you will be kept securely in a locked filing cabinet, and/or on password-protected secure computer files at the RDNS Helen Macpherson Smith Institute of Community Health. After the project is completed, all information would be kept for five years in the archive at the RDNS Helen Macpherson Smith Institute of Community Health. Following five years, all information would be destroyed. Only the Project Team have access to the information. If you have any concerns the Project Team are not able to answer or complaints about the conduct of this project please contact: Mr Mark Smith Chair RDNS Research Ethics Committee RDNS Helen Macpherson Smith Institute of Community Health, 31 Alma Road St. Kilda, Victoria, 3182 Phone (03) 9536 5382, Fax (03) 9536 5300 Email [email protected]

123

Appendix N – Consent Form (Staff Focus Group)


Consent Form – Focus Group


of (insert your work address in capital letters)


The details of this project have been explained to me verbally, and

I have received a copy of the Plain Language Statement, and

Any questions I have asked in regard to this project have been answered to my satisfaction, and

I understand that any information I provide will be treated with the strictest confidence.

I agree to participate in this project and understand that I may withdraw without my employment being affected in any way. I agree that data provided by me may be used in a report, presented at conferences or published in journals on the condition that neither my name nor any other identifying information is used.

Signature of participant


Witnessed by


124

Appendix O – Staff Focus Group Interview Guidelines

The following questions will guide the focus group. As the focus group is semi-structured, additional questions based on answers may be asked and relevant tangents explored.

Experiences working with RDNS HIV/AIDS clients with mental health/substance use problems

1. What are the most commonly occurring mental health and/or substance use problems for these clients?

2. What are the most common health difficulties for these clients? 3. What are the most common social and housing difficulties for these clients? 4. What have been your experiences in providing nursing care to RDNS HIV/AIDS clients with

mental health and/or substance use problems before the trial of the Mental Health Nurse commenced?

5. (And with clients also experiencing cognitive impairment)? 6. What are some of the main issues for RDNS nurses in providing care to RDNS HIV/AIDS

clients with mental health and or substance use problems? 7. (And with clients also experiencing cognitive impairment?) 8. How effectively do RDNS nurses deal with the common health and social difficulties

experienced by these clients? 9. (And with clients also experiencing cognitive impairment)? 10. When a client is referred with HIV/AIDS and concurrent mental health and/or substance use

problems is there sufficient information provided? 11. When HIV/AIDS clients are found to have mental health and/or substance use issues, or

changes in these health domains, how was this managed before the Mental Health Nurse role commenced?

12. What were the main barriers to care provision for these clients before the Mental Health Nurse role commenced?

Effectiveness of the Mental Health Nurse role within the HIV/AIDS Team

1. Do you think the Mental Health Nurse role really did improve mental health care for clients?

Explore

If so, how?

If not, why not?

2. How effectively did the Mental Health Nurse role collaborate with RDNS nurses, and with external service providers?

Usefulness of the Mental Health Nurse role in directing clinical decision making

1. How did the Mental Health Nurse role contribute to care? 2. What was most useful about the Mental Health Nurse role?

If so, which part and why?

Acceptability of the role to clients

1. When you were recruiting clients amongst those who said ‘No’ were there some with mental health problems?

125

Explore

2. How acceptable do you think the Mental Health Nurse role was to clients?

Explore

Acceptability of the role to nurses

1. How hard was it to refer to the Mental Health Nurse? 2. What role should RDNS nurses play in problem identification and referral to a Mental Health

Nurse? 3. How comfortable were you in sharing care with the Mental Health Nurse? 4. How effective was the role in providing centre based/client focused education to nurses? 5. What did you find most helpful about the role? 6. How acceptable was the role to you?

Would anyone like to make any additional comment/s regarding the trial or suggest any improvements?

126

Appendix P – Plain Language Statement (External Providers)


Plain Language Statement – Information Letter for External Providers

Project Team:


Liz Crock HIV/AIDS Clinical Nurse Consultant, RDNS Yarra Centre Adam Hamilton Mental Health Clinical Nurse Consultant, RDNS Yarra Centre Maureen Wilkinson Centre Manager, RDNS Altona Centre Barbara Williams Mental Health Clinical Nurse Consultant, RDNS Essendon Centre Jacqui Allen Project Officer What is the project about? Royal District Nursing Service (RDNS) is conducting this project to better understand how people living with HIV/AIDS can be helped with mental health and drug and alcohol problems. The aim of this project is to develop and test a Mental Health Clinical Nurse Consultant role for RDNS HIV/AIDS clients. The Victorian Department of Human Services is funding the project. This letter tells you about the project. Please read this letter carefully and contact Jacqui Allen, the Project Officer, if you have any questions on 9536 5335 or on email at [email protected]. Your consent: If you agree to participate, you will be part of the project sometime between September to October 2007. You will be invited to participate in a confidential 10-15 minute telephone interview with a member of the Project Team. During this interview, you will be asked about your experiences regarding the Mental Health Clinical Nurse Consultant role on the RDNS HIV/AIDS Team. With your permission, this interview will be audio-taped. If you agree to take part in the project, you will be asked to sign a consent form. By signing the consent form you indicate that you understand this information and that you give your consent to participate in the project. Participation is voluntary. If you decide to say ‘no’, this will not affect your working relationship with RDNS in any way. If you say ‘yes’ now and later decide to withdraw, you can change your mind and tell the Project Officer (contact details are listed above) up to four weeks after your involvement with the project has ended. What are the possible benefits and risks? We cannot advise you that you will directly benefit from this project but you may do so as you would be helping with a project that should help RDNS HIV/AIDS clients in future. It is not likely that you will experience any risks or discomfort from taking part in this project. How will my personal information be used? A report will be written, and journal articles and conference papers may be written. These will include information reported for the entire group of external providers. You will remain anonymous in all of these reports and you will not be identifiable in any report.

127


How will my personal information be kept confidential, private and secure? All information you provide to us will be treated as strictly confidential. Your name or identifying details will not be presented on any reports. Names or incidents that make identification possible will not be included in any material available to anyone outside the Project Team. During the project, all information collected from you will be kept securely in a locked filing cabinet, and/or on password-protected secure computer files at the RDNS Helen Macpherson Smith Institute of Community Health. After the project is completed, all information would be kept for five years in the archive at the RDNS Helen Macpherson Smith Institute of Community Health. Following five years, all information would be destroyed. Only the Project Team have access to the information. If you have any concerns the Project Team are not able to answer or complaints about the conduct of this project please contact: Mr Mark Smith Chair RDNS Research Ethics Committee RDNS Helen Macpherson Smith Institute of Community Health, 31 Alma Road St. Kilda, Victoria, 3182 Phone (03) 9536 5382, Fax (03) 9536 5300 Email [email protected]

128

Appendix Q – Consent Form (External Providers)


Consent Form – External Providers


of (insert your work address in capital letters


The details of this project have been explained to me verbally, and

I have received a copy of the Plain Language Statement, and

Any questions I have asked in regard to this project have been answered to my satisfaction, and

I consent to participate in a telephone interview, and

I understand that any information I provide will be treated with the strictest confidence.

I agree to participate in this project and understand that I may withdraw at any time without my working relationship with RDNS being affected in any way. If I withdraw from the project up to four weeks after my involvement with the project has ended, any data previously collected about me will be destroyed if I request that this occurs. I agree that data provided by me may be used in a report, presented at conferences or published in journals on the condition that neither my name nor any other identifying information is used.

Signature of participant


Witnessed by


129

Appendix R – Phone Interview Guidelines (External Providers)

The following questions will guide the phone interviews. As the phone interview is semi structured, additional questions based on answers may be asked and relevant tangents explored.

1. What have been your experiences in sharing care for clients with HIV/AIDS and concurrent mental health and/or substance use problems with RDNS before the trial of the Mental Health Nurse commenced?

(And with clients also experiencing cognitive impairment)?

2. Do you think the Mental Health Nurse role really did improve mental health care for clients?

Explore

If so, how?

If not, why not?

3. How effectively did the Mental Health Nurse role collaborate with you/your service?

4. How effectively did the Mental Health Nurse role contribute to clinical decision making in regards to clients you shared with the Mental Health Nurse?

5. What did you find most helpful about the role?

6. In your opinion, what are the limitations to care coordination between the RDNS Mental Health Consultant Nurse on the HIV/AIDS Team and your service?

7. How could care coordination between the RDNS Mental Health Consultant Nurse on the HIV/AIDS Team and your service be improved?

130

Appendix S – Transcribers Declaration of Confidentiality

DECLARATION OF CONFIDENTIALITY BY

TRANSCRIBERS OF TAPED DATA

Project Title:

Transcriber (please print details below)

I (full name)

Of (address)

acknowledge that all information transcribed by me for the project named above will be treated by me with the strictest confidence.

Further, I will ensure that all tapes while in my possession will be treated with the same level of confidentiality as the transcribed material and, together with the data, will be stored separately and securely, as stated in the project application.

All material relating to the above project will, while in my possession, be accessible to the evaluator(s) only.

131

Signature:

Date:

Witnessed by: (Print name of Principal Evaluator)

Name: Signature: Date:

132

supporting the mental health needs of people living with ...€¦ · project officer, rdns helen...

Documents