Dual Diagnosis Development in Acute Inpatient Units. Dr Elizabeth Hughes Rose Pringle Ian Wilson Mark Holland

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1 Dual Diagnosis Development in Acute Inpatient Units Dr Elizabeth Hughes Rose Pringle Ian Wilson Mark Holland

2 Aims To be aware of the clinical issues related to co-occurring substance misuse in inpatient mental health settings. To consider the practical issues related to developing training for inpatient mental health staff and their learning needs. To have a greater knowledge of the methods of evaluating the impact of training on service and users

3 Background Dual diagnosis of mental health and substance misuse continues to be a challenge for all mental health services Prevalence studies (Philips and Johnson 2003) have indicated that approximately 50% of people in acute wards have a current co-morbid substance use problems Recent NCISH report (NCISH, 2013) highlights that suicide and homicide related to DD is still not reducing despite incidents reducing in general Opiates are now the most common drug involved in fatal overdose. The effective management of substance misuse in acute inpatient settings is a significant concern.

4 Organisational and training issues Organisations have responsibility to support staff in managing sometimes extremely challenging and complex situations (especially out of hours). Drivers include NHSLA requirements for substance misuse screening and assessment Mental health nurses lack the necessary training and support to effectively assess and care for substance misuse (Hughes et al, 2007). Substance misuse is under-detected by mental health nurses and therefore not addressed effectively. At ward level, there is a lack of consistency with individual nursing responses to critical situations. There is an urgent need for this capability gap to be addressed

5 Previous Inpatient DD training projects Camden and Islington (Hughes et al, 2007) Mass training project- ambitious aim for all inpatient staff to undertake 5 day Pan London training Supervision by clinical nurse specialist as follow-up Supervision poorly attended due to busy units- shift of strategy to focus on one unit at a time Pre-post test evaluation Attitude and confidence shifts baseline to follow-up, as measured by AAPPQ and SES (Hughes, 2008) Anecdotal evidence of reduced verbal and physical conflict in wards where staff had been trained

6 Previous Inpatient DD training projects- cont. Lincoln (Barrett and Roberts, 2010) Pilot project, 50% of the registered nurses from two acute wards (N=5) Collaboration between academic and practice Training delivered in-house in acute ward setting in dialogic group Action research- problem identification, action planning, implementation and reflection Qualitative feedback- more likely to engage in dialogue re substance misuse, attitudinal shifts, recognising the small gains, limits to their own influence (e.g. crap lives and lack of post-discharge treatment and support)

7 Background to the Manchester training project High prevalence of co-existing substance misuse & complex MH issues has been identified in Manchester There have been a number of high profile serious untoward incidents involving this client group; also some near misses particularly methadone, alcohol and new psychoactive substances Significant service development work over past 15years led by Dr Mark Holland Inpatient protocols developed (Wilson et al, 2009) Enhanced role Dual Diagnosis link workers- they required training to enable them to support their colleagues Dual Diagnosis link worker nurses from 10 in-patient areas were identified and agreed to join the training University of York to undertake an independent evaluation.

8 Manchester Training Pilot Aim: To increase the specific dual diagnosis competence of practitioners working with inpatients who experience co-existing mental illness and substance misuse Objectives To develop an understanding of the needs of clients with co-existing mental ill health and substance misuse problems To introduce effective interventions for this client group, based on the cycle of change & motivational interviewing To encourage and support dual diagnosis link workers in their leadership role

9 Outline of Five-day programme Day One: Overview of Dual Diagnosis Day Two: Alcohol Awareness Day Three: Drug awareness Days Four & Five: Introduction to motivational Interviewing & ongoing supervision requirements

10 LIGHT DEEP Kirkpatrick s framework for Evaluation of Training Level 1: trainee reactions- satisfaction with training Level 2: learning acquisition *2a attitudes *2b acquisition of knowledge and skills Level 3: Change in behaviour- behavioural change in workplace as a result of change in attitudes knowledge and skills Level 4: Benefits to service users and carerschanges in service user outcomes

11 Evaluation Plan All link workers will participate in a semi-structured telephone interview Questions posed will focus on: The issues faced as a mental health nurse in working with substance misuse on an inpatient mental health ward. Expectations of the training in terms of developing skills and knowledge for self as well as the team? Considering the content of the training: What was particularly helpful (and why) What was less helpful (and why) (level1) How the training and support has influenced the way they work with substance misuse issues (level 2&3) How do you feel it has changed how they work with your colleagues in relation to substance misuse (level 3) What other training and support needs have been identified? Suggestions regarding how mental health inpatient services work with substance misuse/dual diagnosis issues

12 Limitations of this evaluation Tiny resource available for evaluation (COMO project RCT 200,000 over three years) Small selective sample (not representative) No control/comparison No independent assessment of skills (audio-taped, OSCE etc) No independent measure of direct impact on patient care Attitudinal scales (Co-morbidity Perceptions and Problems Questionnaire- Munroe, 2007) could be used but not sufficiently powered to detect differences (small sample) risk of type 1 and 2 error (false positive or false negative)

13 Recommendations and Conclusions CPD Training is costly and time-consuming- we need to be able to demonstrate a return on investment. In new climate of CPD commissioning, we have to develop more robust ways to demonstrate that CPD changes practice and thereby changes/improves care and service user outcomes So far DD training research has demonstrated some impact on staff outcomes but this has not been shown to translate into improved service user outcomes. We also need to be clear about what is feasible for inpatient staff to implement in a busy chaotic environment with high turn-over of service users. In addition, the role of the wider services needs to be better understood and organised. This is why understanding the training experience from staff viewpoint is vital. There is a need to develop substantial research projects to evaluate the impact of DD training on service user outcomes. Dual diagnosis remains a significant clinical challenge and the data from NCISH indicate that it has not been resolved.

14 Acknowledgements Dr Mark Holland, Consultant Nurse for Dual Diagnosis Manchester Mental Health and Social Care Trust Ian Wilson lecturer-practitioner, Dual Diagnosis trainer, Manchester Mental Health and Social Care Trust

15 References Barrett, P and Roberts, S. (2010) Enhancing dual diagnosis capacities in acute inpatient nurses: A practitioner-based action research project Advances in Dual Diagnosis 3(2), Hughes, E; Robertson, N; Kipping, C; and Lynch, C (2007) The Challenges of Developing Dual Diagnosis Capabilities for Acute Inpatient Staff. Journal of Mental Health Workforce Development Volume 2 (2), p Hughes, E.; Wanigaratne, S, Gournay,K.; Johnson, J, Thornicroft,G; Finch, E.; Marshall, J., and Smith, N. (2008) Training in Dual Diagnosis Interventions (The COMO Study): A Randomised Controlled Trial Biomedical Central Psychiatry. February :12 Munro, A., Watson, H.E., and McFadyen,Y. (2007) Assessing the impact of training on mental health nurses' therapeutic attitudes and knowledge about co-morbidity: a randomised controlled trial. International Journal of Nursing Studies 44(8): National Confidential Inquiry into Suicides and Homicides by people with mental illness (NCISH) (2013) Annual report 3_UK.pdf Phillip, P and Johnson, S. (2003). Drug and alcohol misuse among in-patients ith psychotic illnesses in three inner-london psychiatric units. Psychiatric Bulletin, 27, Ian Wilson, Mark Holland, Vanessa Mason, Josh Reeve, Hayley Ash, (2009) "The management of substance misuse on psychiatric inpatient wards a policy to promote effective good practice", Advances in Dual Diagnosis, 2(4),