A thematic analysis of staff perspectives on the impact of a mental health nurse (RMN) in a critical care unit

Abstract

Background

Recent guidelines in the UK have shaped Critical Care Units (CCUs) to bring the mental health needs of patients, and staff wellbeing to the forefront of service provision. A health board based in NHS Wales has trialled the secondment of a Mental Health Nurse (RMN) within a CCU to help service provision adhere to such guidelines.

Methods

Critical care staff were invited to attend focus groups to share their experiences of how the RMN influenced service provision.

Results

Thematic analysis identified five main themes; including ‘smoother care pathways’, ‘a holistic approach to care’, ‘co-production’, ‘knowledge and confidence’ and ‘staff wellbeing’. Each of these themes reflected how the RMN had both direct and indirect benefits on patient and staff wellbeing.

Conclusion

This qualitative exploration suggests that staff perceived value in the role of the RMN for both staff and patient outcomes, although further measures were considered necessary to improve staff-wellbeing within a critical care environment. This service evaluation supports recommendations for commissioning a RMN permanently in a CCU.

Introduction

To date, the annual intake of patients into critical care exceeds 170,000 across the UK, where over half of these patients experience acute stress and long-term psychological morbidity during and following admission. ¹ In many instances, Critical Care Units (CCUs) have been described as alien environments that are often perceived as traumatic and life-changing, sometimes provoking fear of death and adverse psychological outcomes. ² Therefore, staff face the pressure of dealing with both the physical and mental health needs of patients whilst also managing bed-turnover with the increasing demand for critical care beds. ³ The high prevalence of staff burnout (one third of staff) across CCUs in the UK may not be surprising given the high work-load, time pressures and emotional exhaustion experienced within these environments. ⁴

The heightened demand on staff over the years and the scale of patients experiencing adverse psychological outcomes have shifted attention towards staff and patient psychological wellbeing as a priority to improve across CCUs in the NHS. ⁵ Research has started to explore both the needs of staff and patients within CCUs, including a recent survey that identified 45% of 709 staff working in CCUs experiencing mental health difficulties. ⁶

The psychological needs of both patients and staff in CCUs have recently become embedded in policy; including in the National Institute for Health and Care Excellence recommendations^7,8 and the Guidelines for the Provision of Intensive Care Services (GPICS). ⁵ These guidelines have highlighted the value for a Mental Health Professional to become part of the clinical team to support staff wellbeing and to address patient needs beyond physical health.

However, service provision has fallen short of meeting this recommendation where less than 10% of CCUs incorporate Mental Health Professionals as part of their routine work-force. ⁹ Justifying the need to recruit a Mental Health Professional in a CCU to commissioners may be difficult, as there is a lack of evidence available that explores their value and any benefits in the workplace. ¹⁰ An understanding of the role and benefits of a Mental Health Professional within a CCU setting is needed to determine if this may be a suitable approach to target staff burnout and the mental health needs of patients; two growing concerns across CCU services in the UK.^2,4

A Critical Care Service based in NHS Wales piloted the recruitment of a Mental Health Nurse (RMN) to establish whether this resource filled any mental health need for staff or patients, and the extent at which it improved service provision. The purpose for this service evaluation was to explore the experiences of RMN support from the perspective of staff. The service evaluation may gauge whether an RMN should be recommended for future practice. ¹⁰

Method

Service context

The RMN pilot scheme was fixed-term for a period of 6 months between October 2020 and March 2021 in a CCU based in NHS Wales. The RMN was incorporated into the 7-day staff weekly rota. The RMN was allocated multiple responsibilities to improve the mental health needs of patients and to reduce staff burnout; including

• (1) aiding faster prudent healthcare discharge,

• (2) signposting/referring patients to other mental health disciplines following MDT discussions (e.g. Home and Treatment Teams, Inpatient Mental Health Services and Crisis Services),

• (3) psychosocial support for patients to prevent psychological adversity,

• (4) providing training to improve staff knowledge and confidence (e.g. mental health and substance misuse awareness), and

• (5) promoting reflective practice for staff.

Participants

All staff working in the CCU were invited to join one of three focus groups based on their profession to ensure all perspectives were collected. The study relied on a convenience sampling method by recruiting staff who were able to take time away from the ward when the focus groups were scheduled. A total of nine staff members contributed to all questions asked within the focus groups; including three Doctors, three Allied Health Professionals (Physiotherapists and Occupational Therapists) and three Nurses. The RMN did not take part in the focus groups to limit the likelihood of bias (e.g. staff may have answered questions differently if the RMN was present).

Design and procedure

A qualitative approach was selected due to the exploratory nature of the service evaluation that aims to capture individual staff experiences and how staff make sense of the role of the RMN. Thematic analysis is the recommended approach to analyse under-researched areas of interest, ¹¹ and therefore this methodology was considered suitable for the aims of this service evaluation. Thematic analysis is the process of identifying and analysing patterns within the data to search for themes that are important to the description of the research area ¹² ; in this case the role of the RMN.

Both the Research and Development department of the host health board and the Health Research Authority online decision-making tool confirmed that the study was not identified as ‘research’ and instead a ‘service evaluation’, and therefore ethical review was not required. The Information Governance department advised that staff consent should not be collected for service provision purposes. Instead, an information and debrief form were provided to staff that shared the nature of the service evaluation and the process of anonymity.

A total of three focus groups took place that were facilitated by a Trainee Clinical Psychologist who had no previous relationships with the staff and who worked in a separate service within the same health board. The focus groups took place virtually to abide by COVID-19 restrictions and lasted between 35 and 55 minutes. All three focus groups were recorded using an encrypted recording device provided by Cardiff University. Audio files were transcribed verbatim manually by the Trainee Clinical Psychologist.

All three focus groups followed a semi-structured interview format that incorporated an interview schedule of ten open-ended questions (see Appendix A). The interview schedule was collaboratively developed by the Trainee Clinical Psychologist and their supervisor (Lead Clinical Psychologist for Community Mental Health Teams), the RMN on the secondment in the CCU, and the Professional Lead for Mental Health and Learning Disability Psychology in the Welsh health board.

Data analysis

The six phases of Thematic Analysis were used for the purpose of this service evaluation (see Table 1; completed by the Trainee Clinical Psychologist). ¹¹ A bottom-up approach was used when coding the data as part of phase two. Therefore, the themes identified were strongly linked with the data, as opposed to emerging based on a pre-existing theoretical framework. ¹³ The transcript was coded by two separate coders (Trainee Clinical Psychologist and their supervisor) and Cohen’s Kappa was calculated to determine the inter-rater reliability of the codes generated. The kappa statistic indicated moderate agreement (K_W = 0.42) between the two coders. ¹⁴

Table 1.

Phases of thematic analysis.

Phase	Description of process
1. Familiarising self with the data	Transcribing data; reading and re-reading the data and noting ideas.
2. Generating initial codes	Coding for interesting features of the data, systematically across the data set.
3. Searching for patterns and themes	Reviewing codes and beginning to collate these into potential themes across the data set.
4. Reviewing themes	Checking whether the data supports the themes i.e. at the level of the coded extracts and across the data set; generating an initial map of themes.
5. Defining and naming themes	Refining the thematic map in relation to specific themes and how these link to tell a story; generating clear definition and names of themes.
6. Writing the analysis	Selecting vivid extracts to illustrate themes; analysing these in relation to the research question.

Sensitivity to context, commitment and rigour, transparency and coherence, and impact and importance were followed to ensure credibility for the qualitative analysis. ¹⁵

Results

Five key themes were established from the six phases of Thematic Analysis; as presented in Figure 1; three of which reflect the impact of the RMN on patients and two reflect the impact on staff. Descriptions and quotations associated with each theme are presented below (see Appendix B for further examples of staff quotations for each of the five themes).

Figure 1.

A thematic map that presents the five themes developed from the Thematic Analysis that explored staff perspectives of an mental health nurse within a critical care unit.

Theme 1: Smoother care pathways

Staff emphasised the ease of navigating themselves around a complex mental health system when making referrals with the instruction and support from the RMN, as opposed to “wasting a lot of time going around in circles”.

“I’d say sometimes you don’t know if it is an inappropriate referral, you might potentially not pick up the phone and do it, whereas if the RMN is there you can ask them.” (Line 230–231; focus group two)

The RMN was also found to fill a gap by debriefing follow up/discharge services of specific needs to help establish consistency and continuity of care:

“we’d rehab them this way and sort of get them off the ICU, and they get onto the wards and then it is sort of like ‘what about all of this other sort of stuff’ and that’s when the ball starts rolling but there is a considerable delay in that taking place, whereas the RMN’s flagged it up to whoever the RMN has passed it onto” (Line 329–332; focus group two)

Theme 2: A holistic approach to care

Staff suggested that the expertise and knowledge of the RMN helped “tweak how I then went on to work with patients” by driving an alternative perspective about patient presentations that focuses on the biopsychosocial framework. This has shifted the focus away from solely prioritising physical health needs and instead attending to the holistic needs of the patients at an earlier stage in the patients’ care and treatment.

“We can now make more of the mental health problems as sort of higher up on our list of things that we can do, rather than when we discharge them to the ward now we can address that, whereas now they get it from the moment we come which is obviously more advantageous to them” (Line 79–82; focus group two)

Theme 3: Co-production

It was felt that communication with patients and their families had improved where the RMN was able to have difficult conversations with them that helped promote agreeableness and engagement with care and treatment, and provided the platform for individuals to make sense of what has happened to them or their loved ones.

“a couple of examples where they have really displayed their skillset is having difficult conversations with patients that perhaps the medical side of the team were struggling with” (Line 342–344; focus group two)

Theme 4: Staff knowledge and confidence

Staff reported feeling increasingly knowledgeable and more comfortable and open to discussions around “mental health needs”, “mental health capacity” and the “Deprivation of Liberty Safeguards (DoLS)”. The availability of the RMN on the unit eased pressure on staff by providing the platform to undertake collaborative work and by providing the space for staff to ask questions (informally and formally) regarding care and treatment that may have a mental health component:

“That has given us the confidence to ask for help with patients where as we would have perhaps sort of bashed on, but we wouldn’t have bothered to make a referral to anybody else outside because it wasn’t that level of need” (Line 147–150; focus group one)

Theme 5: Staff wellbeing

Staff reflected on the direct and indirect influence of the RMN on their own wellbeing and the wellbeing of the clinical team. They shared how staff wellbeing had been affected “positively”, as the RMN had “filled a gap in our knowledge and it has helped improve our service for patients and that’s taken a load off our shoulders at times.” The RMN was described as a valuable resource within the critical care team by providing the service with “the necessary tools for staff to be able to care, helps the staff wellbeing.” (Line 354–357; focus group one)

However, the RMN only appeared able to focus directly on staff wellbeing on an informal basis through “Corridor conversations”. Although this was perceived to add some value, staff shared that “there are a few areas where perhaps a RMN, their role wouldn’t stretch to…. I think one of the aspects of that which will be really interesting to explore further is the input of a Psychologist.” (Line 200–202; focus group three)

Discussion

The service evaluation aimed to explore experiences of RMN support within a CCU from the perspective of staff. The Thematic Analysis identified five main themes that reflected staff perspectives; including ‘smoother care pathways’, ‘a holistic approach to care’, ‘co-production’, ‘staff knowledge and confidence’ and ‘staff wellbeing’. The themes collectively suggest that staff perceive some value in the role of an RMN within a CCU environment.

The RMN appears to have helped bring mental health needs to the forefront of patient care by directly working closely with patients and improving continuity of care, but also indirectly by improving staff knowledge around mental health. This increase in mental health awareness was noted to transfer into clinical practice where staff felt they were able to consider patient needs more holistically, shifting away from solely focusing on physical health factors. ¹ The indirect benefits of promoting staff knowledge around mental health were also found to improve staff wellbeing by helping build staff confidence when working with patients who present with mental health difficulties. The RMN was also described to take responsibilities away from staff in the CCU, which indirectly promoted their wellbeing by reducing staff burnout. ¹⁶ Therefore, the themes that emerged from the focus groups support current guidelines that recommend a Mental Health Professional be recruited into CCUs across the UK.^5,7

However, the perspectives shared in the focus groups suggest there may still be a gap in meeting the wellbeing needs for staff. The demands placed on staff (including the RMN) to support patient care may have left limited time for staff wellbeing to be directly prioritised and supported, which may explain why staff recognised few direct benefits on staff wellbeing. Moreover, staff responses suggest the role of the RMN may not be suited to meet the needs of supporting staff wellbeing, and instead a Psychologist may be more appropriate to fit into this role. ⁹ There is a growing interest across the NHS to expand the psychology workforce to support staff and patient wellbeing needs in physical health environments; including CCUs. ⁹ However, future research is important to understand how a Psychologist can be implemented into a CCU to promote best practice, but also to help build an evidence-base of effective psychological approaches that improve staff wellbeing. ¹⁷

The themes that emerged from the focus groups also demonstrate how the pilot scheme of an RMN promoted practice in line with NICE and GPICS recommendations (clinical guideline 83).^5,7 Movement towards a holistic approach of patient care beyond dealing with physical health needs likely helped the overall staff agenda shift from reducing fatality estimates to promoting the quality of survival. Moreover, the reported improvement in communication with patients and families may have helped them make better sense of their care and treatment.

The study took place during the COVID-19 pandemic, which limited any possibility of exploring patient perspectives due to government restrictions. Patient experiences within a critical care setting have been explored previously, ¹⁸ but not in the context of understanding the mental health needs of patients or how they respond to a mental health professional being part of their care and treatment team. This information would help determine whether recruitment of a Mental Health Professional should be placed on a statutory footing in CCUs. Moreover, the themes generated from the focus groups may be skewed by the reliance of a naturalistic sample and the impact of the COVID-19 pandemic on patient mortality and staff burn-out. ⁶ Whether similar themes emerge that reflect staff perspectives in CCUs under normal circumstances would be informative to explore.

In summary, staff perspectives suggest that commissioning an RMN as part of a critical care team may enable the mental health needs of patients to be attended to in practice. However, whether patients themselves perceive value in the role of the RMN to support their mental health would be important to explore to further justify this need in CCUs. Additional measures alongside recruiting an RMN are likely needed to combat against staff burnout in such exhaustive environments (e.g. recruitment of a Psychologist). The level of additional measures to improve staff and patient needs in CCUs requires further exploration to develop evidence-based recommendations for NHS services.

Appendix A.

Table 2.

Interview schedule for the focus groups.

Interview questions
1. How do you feel the secondment of a mental health nurse has influenced service provision?
2. What changes, if any, have you noticed in how the mental health needs of patients have been identified and managed?
3. How do you think the secondment has influenced patient turn-over, and how the service links with ‘Prudent Healthcare’?
4. How has the secondment affected your awareness of the mental health needs of patients, and mental health in general?
5. Has the secondment had any effect on staff confidence and/or self-efficacy in the workplace?
6. How has the overall wellbeing of the team been shaped by the secondment of a mental health nurse?
7. What is your opinion of the benefits of commissioning a mental health nurse within the critical care unit? Do you think this resource is needed?
8. Could you see a role for other mental health professionals in your team alongside nursing (e.g. OT, psychiatry, psychology)? If so, how do you think their input would be helpful?
9. Do you feel other mental health needs (patients/staff/service) require attention in the critical care unit that have yet been addressed? If so, would this be a suitable responsibility for the mental health nurse?
10. What could be added or adjusted to the role of the mental health nurse in the critical care unit that would benefit the service?

Appendix B.

Table 3.

Participant quotations that map onto each of the themes developed using thematic analysis.

Themes	Participant quotations
Smoother care path\ways	“The RMN has been able to come in and both advise us on treatments to provide or prescriptions to give to some of these patients, but also to enable them to be assessed on the unit or transferred to a mental health service, to actually be discharged from the unit to a more appropriate location. So, it’s actually been very good.” (Line 25–29; focus group one) “They’ve been really quite proactive and seeing things there that we are not always aware of, and they sort of up and go with things in the background, and your sometimes not aware of what they have managed to achieve until you suddenly realise that they have done it, or the patient that was there has now moved to an appropriate location.” (Line 55–59; focus group one) “But I do think.. I do think actually that the RMNs secondment here supported us on atleast one occasion when we had a patient. They would.. it was a self harm patient.. they were very involved.. very early and that was a smooth process, and I definitely think that it enhances the patient’s journey.” (Line 157–160; focus group three)
A holistic approach to care	“Because historically I think we’ve probably don’t necessarily manage those patients as well as we could or should because it’s not really, really we do the physical side of it, but the rest of it is kind of over there somewhere.” (Line 42–44; focus group one) “The RMN certainly moved onto looking at things not just outside the direct psychiatric/mental treatment, but I think they’re beginning now to look in terms of prevention, prevention of delirium, communication with the patient, working with the OTs. Umm.. so over the months the RMN has developed from a sort of stand alone mental health input to being part of the team that is working together in a inter-modular ways.” (Line 60–64; focus group one) “I’m gonna say the RMN particularly as an individual is very able to bring that in, to bring that sort of um.. angle in to a lot of the sort of case discussions. So, um.. whereas sometimes if that is not practical at that point, from another professionals point of view, for example I might be really focused on delirium management, and actually they are sort of sensing their mood is dipping. Just having that angle quickly makes me tweak how I am then going to work with that person.” (Line 89–94; focus group two)
Co-production	“there’s the medical aspect of it if they’ve had a medical issue and that’s usually followed up with some psychological support for the families.” (Line 192–193; focus group three) “ we were able to get the RMN involved straight away. So, no lag time, no delay in wait for that sort of mood to fester at all. Straight in there and had a conversation.. um.. discussion talked about sleep which is required on the ward. And how important sleep is to recovering, and reinforce that. So, that was then adhered to. Seeing him at home then, he specifically made a point of mentioning the RMN, although he doesn’t need them at the moment, he knows who to contact, and that was enough reassurance for him to go home, and you know, perhaps he might not have otherwise.” (Line 54–61; focus group two)
Staff knowledge and confidence	“One is education with Nursing and Medical staff, because although in terms of self-learning we have a really good idea of factual aspects of the Mental capacity Act and DOLS and things like that. Perhaps we are not so good in the day to day application. So in that respect the education has been good.” (Line 13–16; focus group one) “I think from a nursing point of view it has given the nurses confidence more. Sometimes they feel as if they haven’t got the tools to be able to deal with some of the patients or some of the patients’ issues. Whereas there is somebody they can quite easily get help and support from.” (Line 19–22; focus group three)
Staff wellbeing	“Everyone sits together and debriefs after a particular shift, and I think the RMN almost through coffee room chat has helped them work through issues, I am not denying that they haven’t been there for their mental health, but I think the largest difference they have made is by actually helping them do the job that they want to do.” (Line 259–263; focus group three) “I think certainly from a nursing point of view and I am probably speaking from medical staff as well. What helps all of our mental health is when we feel we are able to look after our patients to the best of our ability and the way that we would want to look after people.” (Line 237–240; focus group three)

ORCID iD

Charlotte Hill https://orcid.org/0000-0003-3475-3118