Abstract
Aims
To evaluate the effectiveness of a mental health screening form for early identification and care escalation of mental health issues in general settings. A secondary aim was to explore general nurses' use of the form and their confidence to discuss mental health issues with patients.
Methods
A cross‐sectional design comprising a review of clinical records to determine use of the form, instances of missed care and escalation to the mental health team. The survey focused on nurses' confidence in general settings to engage in discussions with patients about mental health. Data were collected from April to December 2022. The Strengthening the Reporting of Observational Studies in Epidemiology Statement guided this study.
Results
Of 400 patient records, 397 were analysed; 293 (73.8%) of those had mental health screening by nurses. Age was a significant factor, with younger patients more likely to be screened although concerns were typically recognized in older patients. Of the 20 patients identified with mental health concerns, 9 (45%) were referred for further evaluation by the Clinical Liaison Team. While nurses were proactive in assessing physical risks, assessing risk factors that required deeper conversations with patients, including psychiatric history, was lacking. The survey highlighted fewer than half of the respondents (46%, n = 10) felt competent to engage in discussions about mental health; however, most (59%, n = 13) knew when to seek a mental health referral.
Conclusions
General nurses have a role in the early identification and referral of patients with mental health challenges. However, training is imperative to facilitate deeper patient interactions concerning mental health. Integrating mental health checks within general settings is crucial for early detection and intervention, aligning with global quality care standards.
Reporting Method
STROBE guidelines.
Patient or Public Contribution
We received feedback that shaped the research protocol from a consumer representative.
Keywords: adult nursing, mental health, nurse roles, quantitative approaches, screening
1. INTRODUCTION
Mental health issues are a global problem and while disproportionately affecting people from low and middle‐income countries, high‐income countries are also affected with the World Health Organization (WHO) identifying that between 35% and 50% of people with severe mental health problems receive no treatment (WHO, 2021). The WHO recognize mental disorders as having a significant burden of disease worldwide with depression and anxiety disorders being the most common diagnosis (WHO, 2021). The Australian Bureau of Statistics (ABS) National Study of Mental Health and Wellbeing (2023) found that 42.9% of people aged 16–85 years in Australia have been impacted by a mental health issue at some point in their lives with 21.5% of the population experiencing an issue extending for 12 months or more. Of those experiencing longer term issues 17.2% had a diagnosed anxiety disorder and 4.9% had a diagnosis of depression. Having a long‐term physical health problem also increases the risk of experiencing a major depressive disorder which in turn can impact physical health clinical outcomes (Gold et al., 2020). Furthermore, living with a life limiting illness has been identified as a potential cause of mental health issues and may also exacerbate symptoms of an existing mental health issue (Howe‐Martin et al., 2018).
The evidence indicates there could be a number of patients experiencing challenges with their mental health who have been admitted to a general hospital setting for a physical health‐related problem. The WHO (2022) identified the health sector as having an important role to play in the embedding mental health promotion and prevention strategies in their services requiring active engagement with patients and their families to discuss potential mental health issues. Although the recognition of changes in mental health status is routinely assessed in areas that focus on mental health including acute mental health units or mental health community teams, there is less published about the assessment of mental health in general areas of practice.
While nurses are in a position to consider the holistic needs of patients there remains a reluctance to openly discuss mental health issues when the person presents with a physical health problem (Care Quality Commission, 2020). Responding to clinical deterioration in a timely manner and initiating escalation of care is critical to optimizing patient outcomes. The 2021 National Safety and Quality Health Service (NSQHS) Standards Action 8, highlights the importance of recognizing and responding to acute deterioration in patients, which includes mental state deterioration (Australian Commission on Safety and Quality in Healthcare, 2021). The NSQHS Comprehensive Care Standard: Minimising patient harm criteria Action 5.31 (Australian Commission on Safety and Quality in Healthcare, 2021) also identifies predicting, preventing and managing self‐harm and suicide as key to improving early access to services and support. These standards apply to all areas of practice within the Australian healthcare context including areas where people predominantly present with physical health issues. Given the prevalence of mental health issues in the general population it is highly likely that nurses in general settings will encounter people also experiencing challenges with their mental health. It is therefore important that nurses are able to assess mental health and identify when referral may be required.
2. BACKGROUND
People who experience mental health problems are more likely to have coexisting conditions that contribute to the overall burden of disease (Giandinoto & Edward, 2015). Firth et al. (2019) identified that people with mental health issues across all diagnostic categories are at higher risk of physical health issues, up to 40% compared to the rest of the population. Studies have also acknowledged that people experiencing longer term mental health issues are more likely to have physical health conditions diagnosed later in the disease trajectory and a reduced life expectancy (Edmunds, 2018; The Schizophrenia Commission, 2012). A systematic review and meta‐analysis completed by Walker et al. (2015) included 203 studies from 29 countries and found the mortality of people with mental illness is higher than the general population with the median years of life lost being 10 years, a disparity that is compounded by complexity but needs to be addressed.
Physical health issues can be exacerbated by reduced help seeking behaviours and lifestyle factors such as inactivity, poor diet, obesity and an increased use of substances which may in turn lead to an increased likelihood of a general hospital admission (Gold et al., 2020; Sara et al., 2021). Sara et al. (2021) found that people with mental health issues required hospital admissions for physical health conditions from a younger age and presented with conditions that were similar to those experienced by people aged 60 years and over in the general population. In a recent systematic umbrella review, van Niekerk et al. (2022) estimated that around a third of people admitted to hospital with physical health problems had at least one mental health issue.
The absence of health services that include routine mental health screening for patients in the general clinical environment is of concern. Research points to the challenge of integrating mental health assessments in non‐psychiatric settings, noting that such integration is essential for early detection and intervention (Care Quality Commission, 2020; Rayner et al., 2014). Rayner et al. (2014) argue for a more proactive approach to mental health screening in general clinical environments to reduce health inequalities. The provision of services that help to address the physical health disparities for people experiencing mental health issues is a global concern and nurses are ideally placed to support the identification of mental health issues in general settings.
Nurses are involved in the person's hospital journey from admission to discharge. Their level of patient contact means nurses can work in collaboration with patients, carers and families to complete a holistic assessment that can identify when a patient may be at risk of or have thoughts of self‐harm or suicide and can effectively respond to patients who are distressed (Australian Commission on Safety and Quality in Healthcare, 2021). Despite this requirement nurses in general clinical settings often lack knowledge and confidence to discuss mental health issues with patients in their care (Ngune et al., 2021; Weare et al., 2019). Weare et al. (2019, p. 40) identified 48.7% of the cohort of general nurses in their study were concerned that they might ‘say the wrong thing’ and less than a quarter of participants were confident they could complete a basic mental state examination or risk assessment. The evidence indicates a lack of knowledge about mental illness in general settings and staff are concerned about working outside of their scope of practice (Giandinoto & Edward, 2015; Ngune et al., 2021; Weare et al., 2019).
The Australian Commission on Safety and Quality in Healthcare (2021) has identified best practice criteria including the establishment of organizational wide systems to support the delivery of appropriate and timely care once any acute deterioration in physical and/or mental health has been identified. While ideally people would access screening through their primary healthcare provider research suggests that this is not occurring (Ngune et al., 2024) and the Emergency Department (ED) is where patients most commonly present with mental health issues, self‐harm or following a non‐fatal suicide attempt. The mental health triage tool developed by the Department of Health and Ageing (2007) provides a framework for escalating the care of people presenting to EDs with potential mental health issues. However, this tool has not been designed for use in a general setting where the presenting issue is more likely to be a physical health issue than mental illness. The Australian Commission on Safety and Quality in Healthcare (2021) does however require all general hospitals to put measures in place to recognize and respond to deterioration of mental health in the general clinical environment. Such evidence highlights the need for a proactive approach to mental health screening in general healthcare settings, advocating for a holistic, integrative approach to patient care that equally prioritizes mental and physical health.
This study was developed in response to work that was being completed by the staff at one site within a healthcare organization to address the Australian Commission on Safety and Quality in Healthcare (2021) standard 8.12: responding to deterioration. The ED staff had access to specialist support through the Mental Health Observation and Assessment (MHOA) unit integrated into the ED which is staffed by mental health nurses. The unit has observational beds for patients who are high risk and/or exhibiting challenging behaviours, resulting from suspected mental health problems. Outside of the ED, there is a Consult Liaison team (CLT) who provides mental health outreach support to the general clinical environments once patients with mental health issues have been identified. This system relied on staff recognizing a mental health issue or the patient or family divulging mental health issues, which had not been previously disclosed or observed in the ED, resulting in a reactive approach rather than a proactive one to ensure timely delivery of mental health care and advice for general clinical staff.
The study reported in this paper was exploring the use of a form to promote conversations to improve the detection of potential mental health problems in patients admitted to one of the four general clinical environments participating in this study. This is a proactive approach to mental health in general settings to support the early identification of mental health issues, self‐harm and suicidal thoughts to facilitate the timely referral to mental health services in a tertiary setting within metropolitan Western Australia.
3. AIMS
The aims of this study were to investigate the effectiveness of a mental health screening form in the early identification of mental health issues and escalation of care. A secondary aim was to explore nurses' use of the form and confidence to discuss mental health issues, self‐harm and suicidal thoughts in general settings.
4. METHODS/METHODOLOGY
4.1. Design
A descriptive cross sectional study design was used for this study (Maier et al., 2023). The design comprised of two phases, a review of clinical records (phase 1) and a survey of staff who had used the assessment form in the participating general clinical settings (phase 2). The clinical records identified compliance with the use of the form, any incidences of missed care and incidents of escalation to the mental health team. The survey comprised of closed and open‐ended questions to explore how nurses completed the mental health assessment form (the development of the form is described below). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement (von Elm et al., 2014) was used to guide the framework of this study (see Supplementary File 1). The design incorporates the background literature and rationale for the study, methods, presentation and discussion of the results. The study objectives and design have been provided to support the methods. The methods identify data sources and variables of interest. Descriptive and summary measures are presented within the results. Key results have been discussed while taking into account the study objectives.
4.2. Mental health assessment form
The assessment form was developed for the purposes of the project by a team of experienced mental health nurses, led by clinical liaison team (CLT) members at the study site ensuring face validity. The intention was to provide a framework to guide staff working in the general clinical environment to assess for mental health issues and escalate care where indicated. The form had three questions aligning with the requirements of the NSQHS (Australian Commission on Safety and Quality in Healthcare, 2021) and were designed to assess for the presence or absence of mental health concerns, self‐harm and clinician or caregiver concerns about the patient's mental state. The included questions act as a prompt to explore additional risk factors, and risk indicators and guide the nurse to use suggested screening tools. The form also prompted nurses to consider utilizing other widely used screening tools such as a cognitive impairment/delirium screening tool, the Abbey Pain Scale, drug and alcohol screening and nicotine dependence assessment. Where concerns were identified, care was escalated to the resident doctor for additional assessment and a potential referral to the CLT. If no issues or concerns were identified on admission, nurses were encouraged to complete the form during any other patient/nurse interactions or if mental health concerns were raised or identified by the patient, staff or other carers.
4.3. Setting
The setting for this study was a hospital in metropolitan Western Australia. The assessment form was implemented in four general clinical environments which included the following specialties, one medical assessment unit, one stroke rehabilitation ward and two general medical wards. The admitting nurses from the participating clinical areas were asked by the clinical nurse managers to complete the mental health assessment form for all patients.
4.4. Sample
4.4.1. Phase 1: Review of clinical records
Data from the clinical records were collected from April to December 2022 for patients admitted between May 2021 and December 2022 in the four areas. A total of 1224 patients were admitted to the four clinical areas during the selected time period. A hundred records from each of the four participating clinical areas were included in the study. A power sample size analysis for chi‐square tests calculated using G*Power3 (Faul et al., 2007); power = 0.80; df = 2 effect size (d = .50), and an alpha of .05, demonstrated that a total of 300 records would be sufficient to detect a significant association. A similar study that screened patients for mental health concerns in an oncology setting was able to obtain statistically significant results based on a sample of 286 admissions over a 3‐month period (Howe‐Martin et al., 2018).
4.4.2. Phase 2: Nurses
All registered and enrolled nurses from the participating wards (n = 200) were invited to complete the survey during the data collection period (April to December 2022). Initially, the research team attended a staff development meeting with the clinical managers to explore the recruitment to phase 2. Staff were invited to participate through their clinical managers and using posters in clinical areas, staff rooms and changing areas with QR codes to the survey. Leaflets were also left in areas where the clinical staff write their records. A power analysis for this part of the study was not calculated as the researchers viewed this arm of the study to be complementary to the retrospective review of clinical records.
4.5. Data collection
4.5.1. Phase 1 data collection
Data were gathered through a retrospective review of patient records and a survey of nurses from the participating wards. A hundred records, from each of the four participating areas were randomly selected by the health information records team using a random generator of unique medical records numbers. De‐identified demographic and clinical characteristics of patients, such as age, gender, admitting diagnosis, admitting ward and Indigenous status, were collected. Data extraction was completed from paper‐based patient records and the assessment form used by the nurses to assess for mental health concerns. Data recorded on the form by nurses, assessment by the resident doctor and any subsequent referral information were extracted and informed by the structure of the mental health assessment form.
4.5.2. Phase 2 data collection
To explore nurses' confidence in using the form to facilitate discussions about mental health issues, nurses from the participating wards were invited to complete an online survey. Survey questions comprising demographic and validated questions on levels of confidence to ask about self‐harm, adapted from Groschwitz et al. (2017) were included. Four questions about confidence, ‘I would feel competent if a patient approached me to talk about self‐harm’; ‘I am confident I would know what steps to take’; ‘I am confident that I would know how to react’; 'I am confident that I would know when a consultation with myself would be appropriate and when a mental health referral is required’ were used (Cronbach's alpha = .89–.91). The questions were in Likert scale format (1 = strongly disagree to 5 = strongly agree). Open‐ended questions were used to elicit additional information about the assessment form in relation to what had worked well, the challenges and areas for improvement along with a question asking what inhibited the use of the tool.
A link to the survey was shared by the mental health clinical nurse specialist to staff via the organizational email addresses. To maximize completion, participants were offered options for responding including via QR codes of the survey in the staffroom and an online link. All nurses were informed that their participation/non‐participation would not impact their employment within the hospital or other agencies.
4.6. Data analysis
Data were analysed using IBM SPSS software (IBM, 2018). Descriptive statistics, such as gender and diagnosis, were presented as frequencies and counts for categorical variables. Continuous variables such as age, were explored using measures of central tendencies, such as mean and standard deviation. Pearson's chi‐square for categorical variables and an independent sample t‐test for continuous variables will be used to examine the characteristics of patients who were screened for mental health concerns by nurses. A p value for significant variables was set at .05. Nurses' perceptions of their confidence to ask questions about mental health issues were analysed and presented descriptively.
Data from the survey's open‐ended questions were analysed using descriptive analysis due to the small group of respondents. Qualitative comments were gathered to give voice to staff views on the process, their levels of confidence and any thoughts about support or development needed to facilitate discussions about mental health. The overall aim was to contribute to organizational planning to ensure staff were able to effectively make an initial assessment of mental health and risk.
4.7. Ethical considerations
Ethical approval was obtained from Ramsay Health Care WA/SA Human Research Ethics Committee (Ref: 2154W) on 14 January 2022 and reciprocal ethics from Edith Cowan University Human Research Ethics Committee (Ref: 2022‐3305‐NGUNE) on 22 March 2022. Patient data were de‐identified so they were not linked to the patient records after the data were extracted. The ward areas were identifiable in the data set, as this information was important to the organization in planning ongoing support and training for staff. Informed consent detailing confidentiality, data storage and participants' right to withdraw from the survey were made available via the integrated participant information sheet as part of the online survey for nursing staff. Participants who did not wish to complete the survey once it had been opened had the option to withdraw before starting the survey questions. If participants had started the survey and wished to withdraw, they could do so by simply closing the online browser to shut down the programme. Data submitted up to that point were used in analyses as the researchers were not able to identify individual responses because the survey was anonymous.
4.8. Data management
Questionnaires were completed using the Qualtrics online platform (Qualtrics, n.d.). Questionnaire data were downloaded and stored on the University SharePoint site, a dedicated cloud based secure server, routinely backed up, password protected and accessible only to the research team. Raw data from the assessment form and the referral database were stored in the hospital information records system. Data were de‐identified at the time of data extraction. Patient identifying details such as name and unique medical records number were not collected. Only de‐identified data were stored in the University SharePoint site to facilitate data analysis.
5. RESULTS
5.1. Demographics and clinical characteristics of patients
Data were analysed using descriptive statistics such as frequencies, counts, mean, standard deviation and chi‐square to identify demographic and clinical variables (Table 1). Four hundred records of patients admitted to four wards between May 2021 and December 2022 were randomly selected for the review of patient records. Three records missing details relevant to the study were excluded and of the remaining 397 patient records, 293 (73.8%) had evidence that nurses screened for mental health concerns. There were no statistically significant differences noted between patients screened and those not screened for mental health concerns on the variables of gender (p = .151), admitting diagnosis (p = .235) and admitting clinical area (p = .398). However, patients who were screened for mental health concerns were younger (M = 67.79, SD 19.290) than their counterparts (M = 71.35, SD 15.864), and this difference was statistically significant (p = <.001).
TABLE 1.
Demographic and clinical variables of patients.
| Characteristics | Not screened (n = 104) | Screened (n = 293) | p value |
|---|---|---|---|
| Age (years), mean (SD) | 71.35 (15.864) | 67.79 (19.290) | t = 1.689, df = .395, p = <.001 |
| Gender, n (%) | X 2 = 3.786, df = 2, p = .151 | ||
| Male | 41 (39.4) | 133 (45.4) | |
| Female | 62 (59.6) | 160 (54.6) | |
| Non‐binary | 1 (1.0) | 0 (0) | |
| Indigenous status, n (%) | Not applicable | ||
| Yes | 0 (0) | 4 (1.4) | |
| No | 104 (100) | 289 (98.6) | |
| Admitting diagnoses, n (%) | X 2 = 10.446, df = 8, p = .235 | ||
| Gastro‐intestinal issue | 9 (8.7) | 36 (12.3) | |
| Neurological issue | 25 (24) | 82 (28.0) | |
| Musculoskeletal issue | 20 (19.2) | 57 (19.5) | |
| Endocrine | 5 (4.8) | 8 (2.7) | |
| Genital‐urinary issue | 3 (2.9) | 17 (5.8) | |
| Haematology | 3 (2.9) | 1 (0.3) | |
| Respiratory | 18 (17.3) | 36 (12.3) | |
| Cardiovascular | 16 (15.4) | 38 (13.0) | |
| Other | 5 (4.8) | 17 (5.8) | |
| Clinical area, n (%) | X 2 = 2.961, df = 3, p = .398 | ||
| Medical Assessment Unit | 48 (46.2) | 141 (48.1) | |
| Stroke and Rehab Unit | 20 (19.2) | 74 (25.3) | |
| Private Medical Unit | 13 (12.5) | 29 (9.9) | |
| Public Medical Unit | 23 (22.1) | 49 (16.7) | |
| Identified as having a mental health issue | X 2 = 350.311, df = 2, p < .001 | ||
| Yes | ‐ | 20 (6.8) | |
| No | ‐ | 273 (93.2) | |
Note: Significant p value assessed at .05.
Patients who were screened were mostly admitted to the Medical Assessment Unit (48.1%, n = 141); and had a neurological condition (28%, n = 82) or musculoskeletal issues (19.5%, n = 57). Of the 293 patients, 20 (6.8%) reported a mental health concern or were identified by their family or a staff member as having an issue.
5.2. Characteristics of patients who were identified as having a mental health issue
A further analysis of characteristics of patients with mental health concerns (n = 20) was completed. This group was typically older, (M = 71.35 years, SD 15.864), than the group without mental health concerns (n = 273, M = 67.79 years, SD 19.290). Further exploration of differences between the two groups was not completed due to small numbers in the group where mental health concerns were identified. Table 2 displays the characteristics of patients identified as having a mental health issue.
TABLE 2.
Characteristics of patients who were identified as having a mental health issue.
| Characteristics | Total (n = 20) |
|---|---|
| Age (years), mean (SD) | 71.35 (15.864) |
| Gender, n (%) | |
| Male | 6 (30.0) |
| Female | 14 (70) |
| Non‐binary | 0 (0) |
| Admitting diagnoses n (%) | |
| Gastro‐intestinal issue | 2 (10.0) |
| Neurological issue | 7 (35.0) |
| Musculoskeletal issue | 3 (15.0) |
| Endocrine | 1 (5.0) |
| Genital‐urinary issue | 1 (5.0) |
| Haematology | 1 (5.0) |
| Respiratory | 1 (5.0) |
| Cardiovascular | 3 (15.0) |
| Other | 1 (5.0) |
| Clinical area, n (%) | |
| Medical Assessment Unit | 7 (35) |
| Stroke and Rehab Unit | 7 (35) |
| Private Medical Unit | 2 (10) |
| Public Medical Unit | 4 (20) |
| Risk factors assessed n (%) | |
| Yes | 4 (20) |
| No | 16 (80) |
| Risk indicators assessed n (%) | |
| Yes | 17 (85) |
| No | 3 (15) |
| Nursing Actions and screening tools completed n (%) | |
| Yes | 17 (85) |
| No | 3 (15) |
| Mental Health concerns raised by the hospital staff n (%) | |
| Yes | 5 (25) |
| No | 15 (75) |
| Missed referral n (%) | |
| Yes | 11 (55) |
| No | 9 (45) |
| Outcome‐of‐mental health referral | |
| Link to services | 2 (10%) |
| Discharge/transfer to mental health services | 3 (15%) |
| Nursing/companion special observations | 1 (5%) |
| Continue to monitor | 14 (70%) |
The majority of patients were admitted to the Medical Assessment Unit and stroke wards, both wards contributing 70% (n = 14/20) of all patients. Over a third (35%, n = 7/20) of patients were admitted with a neurological condition; most were females (70%, n = 14/20).
Twenty patients were assessed by nurses for clinical issues such as mental health risk factors and indicators and nurse‐specific assessments were completed for issues such as delirium, pain and alcohol and drug use. Data on the risk indicators, risk factors and nursing actions revealed that nurses were proactive in assessing the indicators and nurse‐specific assessments but not the risk factors. A high number of patients (85%, n = 17/20) had their risk indicators, such as signs of distress, and nursing‐specific screenings (85%, n = 17/20), such as screening for delirium, pain and alcohol dependence completed. Only 20% were assessed for mental health risks factors such as past psychiatric history, trauma or history of violence and aggression.
Of the 20 patients with mental health issues, only 9 (45%) were referred to the CLT for further assessment. Overall, while there was a proactive approach to identifying mental health issues in older patients and implementing nursing actions, assessing risk factors and subsequent referrals need strengthening for comprehensive care to occur.
5.3. Nurses' perceived levels of confidence to engage patients in discussions about mental health concerns
Staff from the participating wards were invited to complete the survey (n = 200). Twenty‐two nurses responded to the survey (response rate 11%). Seventeen were female, three were males, one person identified as another gender and another preferred not to say. The majority of respondents were registered nurses (n = 17), and five were enrolled nurses. Their mean age was 37.50 years, SD 12.71. Only five participants had additional mental health training which included in‐house (n = 1), mental health first aid (n = 2) and specialized tertiary training (n = 2).
Participants' perceived confidence levels are illustrated in Table 3. Only 46% of respondents (n = 10) agreed or strongly agreed that they would feel competent if a patient approached them with self‐harm concerns. Fifty‐nine per cent (n = 13) felt they would know the steps they could take if self‐harm concerns were raised and were confident they would know how to react.
TABLE 3.
Respondents' level of confidence to screen for mental health concerns.
| 1 strongly disagree | 2 | 3 | 4 | 5 strongly agree | |
|---|---|---|---|---|---|
| Confidence n (%) | |||||
| I would feel competent if a patient approached me to talk about self‐harm. | 1 (4) | 9 (41) | 7 (32) | 3 (14) | 2 (9) |
| I am confident I would know what steps to take. | 2 (9) | 4 (18) | 7 (32) | 6 (27) | 2 (9) |
| I am confident that I would know how to react. | 3 (14) | 4 (18) | 10 (45) | 3 (14) | 2 (9) |
| I am confident that I would know when a consultation with myself would be appropriate and when a mental health referral is required. | 2 (9) | 4 (18) | 7 (32) | 6 (27) | 3 (14) |
Although a number of respondents (64%, n = 14) identified they did not feel competent to engage in discussions with patients about their mental health concerns, 59% (n = 13) were confident they would know when they were able to manage the discussion and would be able to identify when a mental health referral would be required.
Open‐ended questions suggested the form was useful for some staff to facilitate asking about mental health.
The screening tool worked well at identifying a patient who may have mental health issues without judgement as it is part of the admission paperwork.
However, a lack of privacy in the clinical environment was articulated as a barrier to asking questions about mental health.
It wasn't always appropriate to have these discussions whilst admitting patients in a busy environment where you were trying to complete admission paperwork as quickly as possible, and you were also asking these questions where privacy was almost non‐existent with the majority of patients being in shared rooms.
Some staff articulated that it was difficult asking people about their mental health due to a lack of mental health experience:
For those with mental health issues, they need and deserve the time to have a proper conversation where they feel comfortable and safe to do so. A lot of medical nurses don't have mental health experience and may not be able to deliver these tough to answer questions in a way that is positively received by the patient.
Other staff felt that the form should be completed as needed and according to clinical judgement:
It is not appropriate for every patient; it should be based on the clinical judgement.
The qualitative comments provided additional context about the experience of screening for mental health issues. The challenges identified are useful in considering the barriers that may impact the confidence of staff in asking about mental health as part of a comprehensive assessment.
6. DISCUSSION
This study examined how nurses in the general clinical settings could support the early identification and referral of patients presenting with mental health issues. Our findings showed that the general nurses in this study had the capacity to screen and refer patients with mental health concerns. Over 70% of patients admitted during the study period were screened by nurses for mental health concerns. Thirty per cent of forms were not completed with the reasons for this being unclear. This would benefit from further research to gain insight into the barriers and facilitators from the nurses' perspectives.
Of the 70% of completed forms, 6.8% identified patients as having a mental health concern at the time of admission. The findings demonstrate the role general nurses could play in identifying mental health concerns, and this aligns with quality and safety indicators for early intervention and the potential to reduce the impact of mental health issues (Australian Commission on Safety and Quality in Healthcare, 2021). Our findings showed that general nurses were confident in assessing patients for behavioural issues that could be measured physically, such as delirium, pain assessment and drug and alcohol dependence. Eighty‐five per cent of the patients with mental health concerns had these issues assessed. However, only 20% of patients were probed for past psychiatric history, history of trauma and/or aggression. The small proportion of patients assessed for psychiatric risks indicated that general nurses may not be confident engaging patients in discussions about mental health concerns. This observation was also supported by the results of the survey.
Eighty‐seven per cent of the survey participants felt unconfident if a patient expressed self‐harm concerns and were unsure of the steps to take in such situations, similar findings have been reported elsewhere (Ngune et al., 2021; Weare et al., 2019). The results suggest that more support through training is needed to equip general nurses with skills to improve their confidence to engage patients in discussions about mental health concerns. This is not unique to Australia, in the UK the Care Quality Commission (2020) identified that staff in general clinical environments felt unsupported and unprepared to meet the mental health needs of patients in their care. A qualitative study of ED nurses exploring their experiences of working with people who self‐harm showed that while nurses felt confident to manage the physical injuries associated with self‐harm, they were less confident to engage with the person about their self‐harm (McGough et al., 2022). Study findings emphasize the importance of providing guidance and training for general nurses to develop the knowledge and skills to assess and intervene with people who present with mental health concerns (Care Quality Commission, 2020; McGough et al., 2022). The aim should be to build nurses self‐confidence to openly discuss mental health and not to worry about saying the wrong thing (Weare et al., 2019).
The findings from our survey showed that 41% (n = 9) of nurses were confident they would know when they could manage the consultation or conversation and when it would be beneficial for them to make a referral for mental health advice and support. These results support the review of clinical records. Nine patients out of 20 that were identified with a mental health issue were referred to the mental health team for further assessment. It was unclear in our study why some patients who were identified on the form as having mental health issues, were not referred to the medical staff or the CLT for further review. A larger study is needed to explore potential barriers and facilitators to the escalation of care for people with mental health concerns in general clinical environments.
Our study also highlights the prevalence and characteristics of patients who may present with mental health concerns in the general clinical environment. The observation that 6.8% of patients who were screened had mental health issues and could have remained undetected without systematic efforts to identify them, underscores the necessity of regular mental health screening in general clinical environments. Physical health assessments have been a focus in mental health services due to the impact on quality of life and life expectancy (National Mental Health Commission, 2016), and conversely, there needs to be a stronger emphasis on assessing the mental health of patients in the general clinical environments.
Patients with a mental health concern had an average higher age than those with no mental health concerns emphasizing the importance of screening for mental health issues in older people (Baruch et al., 2019). This echoes the findings of a narrative review by Kiely et al. (2019) identifying the increasing numbers of people globally experiencing issues with their mental health as they become older, this is particularly apparent with older men. In more recent years the focus has been on the detection of delirium in older adults which can also mask other conditions such as depression and dementia. It is recognized that there is a higher incidence of depression in those diagnosed with dementia (Baruch et al., 2019) and the routine assessment for depression in people with cognitive impairment has been recommended (Gillitzer, 2019). In our study, patients with a diagnosis of dementia were not assessed for mental health issues using the assessment form. It was not clear why nurses did not continue with the assessment once cognitive impairment had been established but this is worthy of future exploration, with a larger sample size, given the prevalence and impact of mental health issues in the older population.
Studies have repeatedly found that mental health and physical health are inextricably linked and a failure to engage in discussions about both can lead to poorer health outcomes (Firth et al., 2019; Gold et al., 2020; The Schizophrenia Commission, 2012). Study findings also emphasize the importance of providing guidance and training for general nurses to develop the knowledge and skills to assess and intervene with people who present with mental health concerns (Care Quality Commission, 2020; McGough et al., 2022). The overall aim should be to build nurses self‐confidence to openly discuss mental health and not to worry about saying the wrong thing (Weare et al., 2019). The form used in our study was developed with the aim of providing a structured format to introduce discussions about mental health as a routine part of the assessment process.
7. STRENGTHS AND LIMITATIONS
A strength of this study included the stratified random sampling approach to select the clinical records from the four clinical areas. Drawing random records from four distinct areas may reduce the risk of selection bias and increase the likelihood that the findings are applicable to other similar clinical settings (Neyman, 1992).
The assessment form used in this study to identify mental health concerns was validated by a group of mental health experts which ensured face validity however other psychometric tests were not completed thereby further testing would be needed for its use in other settings. This may reduce the reliability and accuracy of the data collected (Boateng et al., 2018; Bolton, 2001). However, the form was developed by a mental health clinical expert panel for use on the site and incorporated sections that recorded nurse's clinical judgement to identify patients with concerns and facilitate the escalation of care. The form was also not nuanced to different cultural contexts within the patient population. This is an area for development to ensure cultural variations can be captured within an assessment form for mental health issues.
The survey used validated and reliable questions, the open‐ended questions in the survey offered respondents the opportunity to comment in more depth. The comments provided an awareness of the respondents' experiences of using the form in their particular context. However, the low survey response rate may have led to a response bias and is not representative of the perspectives of the wider nursing community (Sivo et al., 2006). To better understand nurses' confidence in having in‐depth conversations with patients about their mental health concerns, a survey involving a larger group of nurses is necessary. Additionally, qualitative research with a larger participant group of nurses may provide further insight into the facilitators and barriers to discussing mental health issues with patients and their families.
7.1. Recommendations
Healthcare providers should acknowledge the valuable role that nurses and other clinical staff in general settings can play in the early recognition of mental health issues and escalation of care to prevent deterioration in mental health status.
Education of nurses and other clinical staff about the importance of assessing patients' mental health status within general settings is recommended including supporting nurses to develop skills and confidence in discussing mental health issues with patients and their families as they would physical health issues.
A larger scale study to explore the impact and cost benefit of a mental health assessment form and early referral strategies in the general patient population is also recommended including examining if the assessment reduces the risk of acute mental deterioration. This could be monitored through critical incidents or the number of incidences of code blacks (emergency assistance for a personal threat or serious safety risk) within a clinical area/department or organization. Furthermore, given the paucity of evidence in this area, more studies are needed to complement the existing evidence.
In our study, the form was developed by an expert panel for use in one organization. Developing a tool that facilitates assessment across different organizations and cultural groups, including the voice of service users and carers would be a recommendation of this study.
7.2. Implications for policy and practice
The findings of this study underscore the role that nurses play in recognizing and escalating mental health concerns in patients in general health settings. Over 70% of patients admitted during the study period were screened by general nurses for mental health issues, indicating that mental health checks are feasible and can be routine in general health settings.
However, for the practice to be embedded, further training is needed to build nurses' confidence to engage with patients in conversations about their mental health. The limited number of patients assessed for mental health risks reveals the potential training gap. Training focusing on engaging patients in discussions about self‐harm, trauma, aggression and enquiring about mental health histories is needed. Such training can ensure that nurses are able to identify mental health concerns and confidently engage in mental health conversations.
This study identified that older patients presented with mental health concerns. The observed higher average age of such patients supports the need for more targeted mental health screenings for older individuals. While the detection of delirium in older adults has gained attention, other mental health issues may remain unrecognised, especially when overshadowed by physical health issues (Overend et al., 2015).
Overall, the findings demonstrate that screening for mental health concerns can be part of a comprehensive approach to assessing patients, and particularly older patients presenting in a general health setting. Nurses working in general clinical environments need to be equipped with necessary skills to improve their confidence to engage with patients in discussions about mental health concerns.
8. CONCLUSION
Our study supports the existing body of literature that shows mental health concerns are prevalent in the population, and therefore, comprehensive assessments, including mental health checks, should be completed for all patients. Furthermore, our findings show that general nurses play a role in the early identification and referral of patients with mental health issues in general clinical settings. However, training is needed to build nurses' confidence to engage patients in deeper conversations about their mental health beyond the initial check. Besides, physical health checks are routine in acute mental health settings, so integrating regular mental health checks in general clinical environments is essential. This will ensure the early identification and escalation of mental health issues, potentially reducing the long‐term impact of untreated mental health issues. Care escalation to improve patient outcomes also aligns with the quality standards for care in many countries.
AUTHOR CONTRIBUTIONS
SB, CS, BB, CC, IN, BE and YM: Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; IN, YM, BE and CS: Involved in drafting the manuscript or revising it critically for important intellectual content; IN, BE, SB, BB, CS, CC and YM: Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; IN, YM and BE: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
FUNDING INFORMATION
This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
PEER REVIEW
The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16214.
STATISTICAL ANALYSIS
The authors have checked to make sure that the submission conforms to the Journal of Advanced Nursing statistical guidelines. The study design follows the STROBE Statement for descriptive cross‐section studies. The design is indicated in the title, the tables are complete, and where applicable footnotes have been provided. The independent and dependent variables are clearly defined, and groupings are described. Potential biases have been acknowledged, and sample sizes have been explained. The analytical methods have considered the sampling strategy. However, reporting of confounders and sensitivity analysis was not applicable because data is presented descriptively. The first author has completed a biostatistics course and is also experienced in quantitative data analysis.
Supporting information
Supplementary File 1.
ACKNOWLEDGEMENTS
We would like to thank Mr. Howard Lance for providing feedback from a service user/consumer perspective that shaped the research protocol for this study. Open access publishing facilitated by Edith Cowan University, as part of the Wiley ‐ Edith Cowan University agreement via the Council of Australian University Librarians.
Ngune, I. , Ewens, B. , Bell, S. , Burns, B. , Sutton, C. , Creswell, C. , & Middlewick, Y. (2025). Nursing assessment of mental health issues in the general clinical environment: A descriptive study. Journal of Advanced Nursing, 81, 5353–5364. 10.1111/jan.16214
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
REFERENCES
- Australian Bureau of Statistics . (2023). National study of mental health and wellbeing 2020–2022 . Retrieved from https://www.abs.gov.au/statistics/health/mental‐health/national‐study‐mental‐health‐and‐wellbeing/latest‐release
- Australian Commission on Safety and Quality in Healthcare . (2021). National safety and quality health service standards (2nd ed.). Australian Commission on Safety and Quality in Healthcare. [Google Scholar]
- Baruch, N. , Burgess, J. , Pillai, M. , & Allan, C. L. (2019). Treatment for depression comorbid with dementia. Evidence‐Based Mental Health, 22(4), 167–171. 10.1136/ebmental-2019-300113 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Boateng, G. O. , Neilands, T. B. , Frongillo, E. A. , Melgar‐Quiñonez, H. R. , & Young, S. L. (2018). Best practices for developing and validating scales for health, social, and behavioral research: A primer. Frontiers in Public Health, 6, 149. 10.3389/fpubh.2018.00149 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bolton, P. (2001). Cross‐cultural validity and reliability testing of a standard psychiatric assessment instrument without a Gold standard. The Journal of Nervous and Mental Disease, 189(4), 238–242. [DOI] [PubMed] [Google Scholar]
- Care Quality Commission . (2020). Assessment of mental health services in acute trusts. Care Quality Commission. [Google Scholar]
- Department of Health and Ageing . (2007). Emergency triage education kit: Triage quick reference guide. Australian Government. [Google Scholar]
- Edmunds, M. (2018). Inequitable physical illness and premature mortality for people with severe mental illness in Australia: A social analysis. Health and Human Rights, 20(1), 273–281. [PMC free article] [PubMed] [Google Scholar]
- Faul, F. , Erdfelder, E. , Lang, A.‐G. , & Buchner, A. (2007). G*power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175–191. 10.3758/bf03193146 [DOI] [PubMed] [Google Scholar]
- Firth, J. , Siddiqi, N. , Koyanagi, A. , Siskind, D. , Rosenbaum, S. , Galletly, C. , Allan, S. , Caneo, C. , Carney, R. , Carvalho, A. F. , Chatterton, M. L. , Correll, C. U. , Curtis, J. , Gaughran, F. , Heald, A. , Hoare, E. , Jackson, S. E. , Kisely, S. , Lovell, K. , … Stubbs, B. (2019). The Lancet Psychiatry Commission: A blueprint for protecting physical health in people with mental illness. The Lancet, 6(8), 675–712. 10.1016/S2215-0366(19)30132-4 [DOI] [PubMed] [Google Scholar]
- Giandinoto, J.‐A. , & Edward, K.‐L. (2015). The phenomenon of co‐morbid physical and mental illness in acute medical care: The lived experience of Australian health professionals. BMC Research Notes, 8(1), 295. 10.1186/s13104-015-1264-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gillitzer, M. (2019). Implementing a depression screening algorithm in a memory clinic. Archives of Psychiatric Nursing, 33(6), 123–128. 10.1016/j.apnu.2019.10.003 [DOI] [PubMed] [Google Scholar]
- Gold, S. M. , Köhler‐Forsberg, O. , Moss‐Morris, R. , Mehnert, A. , Miranda, J. J. , Bullinger, M. , Steptoe, A. , Whooley, M. A. , & Otte, C. (2020). Comorbid depression in medical diseases. Nature Reviews Disease Primers, 6(1), 69. 10.1038/s41572-020-0200-2 [DOI] [PubMed] [Google Scholar]
- Groschwitz, R. , Munz, L. , Straub, J. , Bohnacker, I. , & Plener, P. A.‐O. (2017). Strong schools against suicidality and self‐injury: Evaluation of a workshop for school staff. School Psychology Quarterly, 32(2), 188–198. 10.1037/spq0000185 [DOI] [PubMed] [Google Scholar]
- Howe‐Martin, L. , Jester, B. , Walker, R. , de la Garza, N. , Jha, M. K. , Tovian, C. , Levinson, S. , Argenbright, K. E. , & Trivedi, M. H. (2018). A pilot program for implementing mental health screening, assessment, and navigation in a community‐based cancer center. Psychooncology, 27(2), 683–686. 10.1002/pon.4418 [DOI] [PubMed] [Google Scholar]
- IBM . (2018). IBM SPSS software . Retrieved from https://www.ibm.com/au‐en/analytics
- Kiely, K. M. , Brady, B. , & Byles, J. (2019). Gender, mental health and ageing. Maturitas, 129, 76–84. 10.1016/j.maturitas.2019.09.004 [DOI] [PubMed] [Google Scholar]
- Maier, C. , Thatcher, J. B. , Grover, V. , & Dwivedi, Y. K. (2023). Cross‐sectional research: A critical perspective, use cases, and recommendations for IS research. International Journal of Information Management, 70, 102625. 10.1016/j.ijinfomgt.2023.102625 [DOI] [Google Scholar]
- McGough, S. , Wynaden, D. , Ngune, I. , Janerka, C. , Hasking, P. , & Rees, C. (2022). Emergency nurses' perceptions of the health care system and how it impacts provision of care to people who self‐harm. Collegian, 29(1), 38–43. 10.1016/j.colegn.2021.04.004 [DOI] [Google Scholar]
- National Mental Health Commission . (2016). Equally Well Consensus Statement: Improving the physical health and wellbeing of people living with mental illness in Australia. NMHC. [Google Scholar]
- Neyman, J. (1992). On the two different aspects of the representative method: The method of stratified sampling and the method of purposive selection. In Kotz S. & Johnson N. L. (Eds.), Breakthroughs in statistics: Methodology and distribution (pp. 123–150). Springer. [Google Scholar]
- Ngune, I. , Hasking, P. , McGough, S. , Wynaden, D. , Janerka, C. , & Rees, C. (2021). Perceptions of knowledge, attitude and skills about non‐suicidal self‐injury: A survey of emergency and mental health nurses. International Journal of Mental Health Nursing, 30(3), 635–642. 10.1111/inm.12825 [DOI] [PubMed] [Google Scholar]
- Ngune, I. , Wynaden, D. , & Heslop, K. (2024). Physical health of people with mental illness: A snapshot of consumer engagement in the provision of care in primary care. Issues in Mental Health Nursing, 45, 429–435. 10.1080/01612840.2024.2312180 [DOI] [PubMed] [Google Scholar]
- Overend, K. , Bosanquet, K. , Bailey, D. , Foster, D. , Gascoyne, S. , Lewis, H. , Nutbrown, S. , Woodhouse, R. , Gilbody, S. , & Chew‐Graham, C. (2015). Revealing hidden depression in older people: A qualitative study within a randomised controlled trial. BMC Family Practice, 16(1), 142. 10.1186/s12875-015-0362-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Qualtrics . (n.d.). The experience management software platform . Retrieved from https://www.qualtrics.com/au/platform/
- Rayner, L. , Matcham, F. , Hutton, J. , Stringer, C. , Dobson, J. , Steer, S. , & Hotopf, M. (2014). Embedding integrated mental health assessment and management in general hospital settings: Feasibility, acceptability and the prevalence of common mental disorder. General Hospital Psychiatry, 36(3), 318–324. 10.1016/j.genhosppsych.2013.12.004 [DOI] [PubMed] [Google Scholar]
- Sara, G. , Chen, W. , Large, M. , Ramanuj, P. , Curtis, J. , McMillan, F. , Mulder, C. L. , Currow, D. , & Burgess, P. (2021). Potentially preventable hospitalisations for physical health conditions in community mental health service users: A population‐wide linkage study. Epidemiology and Psychiatric Sciences, 30, e22. 10.1017/S204579602100007X [DOI] [PMC free article] [PubMed] [Google Scholar]
- Sivo, S. A. , Saunders, C. S. , Chang, Q. , & Jiang, J. J. (2006). How low should you go? Low response rates and the validity of inference in is questionnaire research. Journal of the Association of Information Systems, 7, 17. 10.17705/1jais.00093 [DOI] [Google Scholar]
- The Schizophrenia Commission . (2012). The abandoned illness: A report from the Schizophrenia Commission. Rethink Mental Illness. [Google Scholar]
- van Niekerk, M. , Walker, J. , Hobbs, H. , Magill, N. , Toynbee, M. , Steward, B. , Harriss, E. , & Sharpe, M. (2022). The prevalence of psychiatric disorders in general hospital inpatients: A systematic umbrella review. Journal of the Academy of Consultation‐Liaison Psychiatry, 63(6), 567–578. 10.1016/j.jaclp.2022.04.004 [DOI] [PubMed] [Google Scholar]
- von Elm, E. , Altman, D. G. , Egger, M. , Pocock, S. J. , Gøtzsche, P. C. , & Vandenbroucke, J. P. (2014). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. International Journal of Surgery, 12(12), 1495–1499. 10.1016/j.ijsu.2014.07.013 [DOI] [PubMed] [Google Scholar]
- Walker, E. R. , McGee, R. E. , & Druss, B. G. (2015). Mortality in mental disorders and global disease burden implications: A systematic review and meta‐analysis. JAMA Psychiatry, 72(4), 334–341. 10.1001/jamapsychiatry.2014.2502 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Weare, R. , Green, C. , Olasoji, M. , & Plummer, V. (2019). ICU nurses feel unprepared to care for patients with mental illness: A survey of nurses' attitudes, knowledge, and skills. Intensive & Critical Care Nursing, 53, 37–42. 10.1016/j.iccn.2019.03.001 [DOI] [PubMed] [Google Scholar]
- World Health Organization . (2021). Comprehensive mental health action plan 2013–2030. World Health Organization. [Google Scholar]
- World Health Organization . (2022). World mental health report: Transforming mental health for all. World Health Organization. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary File 1.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.