14 The Role of Nurses and Midwives in Health Care
Learning Objectives
- Understand the registration requirements and roles of nurses and midwives in Australia.
- Recognise the importance of integrating mental health care into nursing practice, regardless of specialisation.
- Apply the biopsychosocial model in providing holistic care to patients with co-morbidities.
- Develop skills to identify and address mental health issues in patients presenting with physical health problems.
- Implement effective communication strategies to support patients and their families emotionally and psychologically.
Introduction
This chapter will provide an overview of the role of nursing and midwifery as part of the multidisciplinary team (MDT) within mental health services. The healthcare landscape is ever evolving, requiring nurses and midwives to adapt and expand their roles in managing the complex interplay between physical and mental health. This chapter explores the contemporary responsibilities of nurses and midwives, emphasising the integration of mental health care into their practice. It highlights the importance of a holistic approach, addressing both physical and mental health needs, and provides practical examples and case studies to illustrate these concepts in real-world settings.
Registration for Nurses and Midwives
In Australia, all nurses and midwives must be registered with AHPRA (Australian Health Practitioner Regulation Agency) to ensure compliance and competence in practice. This registration tracks accreditation standards, quality frameworks, and the monitoring and compliance of nurses alongside other health professionals. The rigorous registration process guarantees that healthcare professionals meet the necessary standards to provide high-quality care.
Understanding the Roles of Nurses and Midwives
Nurses: Nurses in Australia work across various settings and are trained to address both physical and mental health needs. Enrolled nursing programs provide mental health placements, while registered nurses undergo university studies, including mental health topics. The Australian College of Mental Health Nurses (ACMHN, 2024) outlines that, to specialise in mental health, registered nurses need additional qualifications such as a graduate certificate, diploma, or master’s degree in mental health nursing. Globally, similar trends are observed where continuous professional development is crucial in maintaining competency in specialised fields like mental health.
Types of Workplaces for Mental Health Nurses
Mental health nurses work in diverse settings, providing care across inpatient, community, and specialized services.
These include:
- Psychiatric Inpatient Units (attached to public and private hospitals)
- Adult, Adolescence,Child, Perinatal, Forensics,Geriatric Services
- Community Mental Health Services
- Telehealth Mental Health Services (e.g., Mental Health Triage – MHT)
- Non-Governmental Organisations (NGOs)
- General Practice (GP Clinics)
- Specialist Youth Services (e.g., HEADSPACE)
- Ambulance Services
- Police Services
- Prisons and Forensic Mental Health Services
Types of Workplaces for Registered or Enrolled Nurses
Registered and enrolled nurses may work in a range of healthcare environments, including:
- Public Hospitals
- Private Hospitals
- General Practice (GP Clinics)
- Telehealth Networks
- Royal District Nursing Service (RDNS) and Community Practice Clinics
- Schools
- Mining and Large Industry Settings
Midwives: Midwives support pregnant individuals and new parents, addressing both physical and mental health. They work in hospitals, clinics, and home visits, providing comprehensive care throughout pregnancy and the postnatal period. Whilst the mental health context may not be completely obvious it needs to be understood that issues such as depression and anxiety can impact a person who is pregnant or had a child, this can also include paternal depression (Kontoyannis, 2022; Gordon et al., 2013). They also recognise and manage mental health concerns such as prenatal and postnatal depression, which can significantly impact both the parent and child. Internationally, midwives are increasingly recognised for their role in promoting mental health, with initiatives like the UK’s National Health Service (NHS) integrating mental health screening into routine prenatal and postnatal care.
Integrating Mental and Physical Health in Nursing Practice
All nurses, regardless of their specialisation, play a role in mental health care. Physical health issues often intertwine with mental health. People with mental illnesses often experience physical symptoms due to the illness itself and its treatments. Mental illnesses can disrupt hormones and sleep, while psychiatric medications may cause side effects like weight gain and heart rhythms that are irregular which puts them at risk of complications in their physical health. Mental illness can increase the individual’s vulnerability to poor physical health by impacting social and cognitive function and reducing energy levels. This can lead to a lack of motivation for healthy behaviours and the adoption of unhealthy habits like poor diet, smoking, and substance abuse, worsening health outcomes. It is therefore important that all nurses regardless of mental health nursing specialisation, become vigilant and skilled in identifying and addressing these complexities. For example:
- A traumatic injury or amputation of a leg may lead to psychological distress.
- A cancer diagnosis can trigger anxiety and depression.
- A person recently diagnosed diabetes experiencing severe anxiety and depression
- Palliative care situations involve significant emotional support for both patients and families.
- Alcohol withdrawal symptoms may also include symptoms of mental illness
- A newly admission patient anxious about ward environment
- A person with co-existing schizophrenia and obesity experiencing side effects of antipsychotic medications.
Nurses worldwide are increasingly adopting a holistic approach, recognising the interdependence of physical and mental health. For instance, in Canada, the integration of mental health care into primary care settings has shown improved outcomes in managing chronic illnesses with co-morbid mental health conditions.
Role of Nurses in Healthcare
Registered Nurses (RNs) in Australia are trained to provide holistic care using a biopsychosocial model, which integrates physical, psychological, and social aspects of health. This comprehensive approach ensures that all factors affecting a person’s health are considered, promoting overall well-being. According to the Australian College of Nursing, this model is essential for addressing the complex needs of patients with mental health conditions (ACN, 2020).
RNs must be skilled at recognising the impacts of mental health and knowing when to refer patients to appropriate mental health services. Nurses must be skilled of recognising deterioration in both physical and mental health and address this as per protocol. Physical health causes of deterioration should always be addressed first, before addressing deterioration in mental state. Nurse should be aware of assessment tools used to support assessment such as level of Aggression scales, Sedation scores, Alcohol withdrawals scores.
Nurses must also be vigilant about the side effects of medications commonly prescribed for mental health conditions. For instance, antipsychotics can cause side effects such as Neuroleptic Malignant Syndrome (NMS), which is a life-threatening reaction characterized by fever, muscle rigidity, and altered mental status (Strawn et al., 2007). Other side effects include Parkinsonism, which presents as tremors and bradykinesia, and metabolic syndrome, which includes weight gain, hyperglycaemia, and dyslipidaemia (Newcomer, 2005). Antidepressants, particularly SSRIs, can lead to Serotonin Syndrome, marked by agitation, confusion, rapid heart rate, and high blood pressure (Boyer & Shannon, 2005). Nurses play a crucial role in monitoring these side effects and referring patients to treating team and other appropriate specialists for management.
In hospitals, nurses can refer patients to mental health liaison teams or hospital psychiatric liaison teams for specialised care. For example, if a patient shows signs of depression or anxiety, the RN can initiate a referral to ensure timely mental health support.
Additionally, nurses can provide opportunistic education about diet, smoking reduction, and the importance of physical activity during their interactions with patients. Every contact with a person living with a mental health condition is an opportunity to monitor for physical health risks. This includes checking vital signs, conducting ECGs, monitoring diabetes, assessing weight, inspecting dentition, checking for infections, discussing sexual health, and evaluating the side effects of medications. Appropriate referrals can then be made to general practitioners (GPs), dieticians, drug and alcohol services, occupational therapists, and physical activity specialists.
Collaboration with community teams is crucial. RNs work with families and carers to ensure comprehensive support. Social workers can assist with housing, financial issues, and relationship problems. Occupational therapists can perform functional assessments, and carer consultants can offer additional support. In Indigenous communities, Aboriginal liaison services play a vital role in culturally appropriate care.
For instance, organisations that provide free meals can be valuable resources for patients struggling with food security. Early intervention services for young people, including referrals to youth services, are critical for addressing mental health issues promptly. As an RN, familiarity with available services and the referral processes is essential for effective patient advocacy during patient care, ensuring that all patient needs are met.
This approach enhances patient care and supports long-term health outcomes. Trends in Australia and globally highlight the increasing use of interprofessional collaboration, where nurses work alongside mental health professionals to deliver integrated care, particularly in community health settings (Happell et al., 2019). By leveraging their training and the available resources, RNs play a pivotal role in the holistic care of patients with co-existing physical and mental health conditions.
Assessment tools to support assessment and care
Registered Nurses can utilise various mental health tools to support care and referrals effectively. The Kessler Psychological Distress Scale (K10) is widely used to assess anxiety and depression levels, providing a quick overview of a patient’s mental health status (Kessler et al., 2002). The Depression, Anxiety, and Stress Scales (DASS) offer a more detailed evaluation of these conditions (Lovibond & Lovibond, 1995).
For cognitive functioning, the Mini-Mental State Examination (MMSE) is a valuable tool for assessing cognitive impairment (Folstein, Folstein, & McHugh, 1975). Additionally, the Patient Health Questionnaire (PHQ-9) and the Generalised Anxiety Disorder 7 (GAD-7) scale are contemporary tools used for screening depression and anxiety, respectively (Kroenke et al., 2001; Spitzer et al., 2006). These tools enable nurses to identify issues early and make appropriate referrals, enhancing patient care.
Advances in Nursing Practice and Global Trends
Advances in technology and evidence-based practices are shaping the future of nursing and midwifery. Telehealth and telemedicine have become vital tools, especially in rural and underserved areas, providing access to mental health care and support. The COVID-19 pandemic accelerated the adoption of these technologies, highlighting their potential in ensuring continuous care. The World Health Organisation (WHO) emphasises the importance of digital health solutions in achieving universal health coverage, a trend echoed in many countries.
Furthermore, global trends indicate a growing emphasis on culturally competent care. Nurses and midwives are trained to understand and respect cultural differences in health beliefs and practices. This cultural competence is essential in providing personalised care that meets the diverse needs of patients, reducing health disparities, and improving outcomes.
Case Examples
Case Study 1: Clarice’s Biopsy Results
- Background: Clarice, a 19-year-old, receives benign biopsy results but is overwhelmed and confused.
- Nursing Intervention: A nurse provides emotional support, explains medical terms, and offers resources for further understanding and emotional support.
- Outcome: Clarice feels informed and supported, with resources and a plan for ongoing care.
Case Study 2: Mrs. Cusack in Hospice Care
- Background: Mrs. Cusack, aged 78, is in hospice care for end-stage pancreatic cancer, with complex pain management needs.
- Family Dynamics: Her son, Johann, struggles with anxiety and depression, impacting his ability to cope with his mother’s condition.
- Nursing Interventions: Nurses provide emotional support, education, and coordination with the palliative care team, ensuring comprehensive care for both Mrs. Cusack and her family.
Case Study 3: Integration of Telehealth in Rural Nursing
- Background: Sarah, a registered nurse, works in a rural community where access to specialised mental health services is limited.
- Intervention: Utilising telehealth, Sarah connects her patients with mental health specialists, ensuring they receive timely consultations and follow-ups.
- Outcome: Patients report improved mental health outcomes and greater satisfaction with the continuity of care provided through telehealth.
Case study 4:
Background: Tahlia, aged 32, in second trimester of pregnancy with her first child. She has no history of mental health concerns, however more recently experiencing increased feelings of sadness, anxiety, and isolation. During a routine check-up, midwife identifies that she seems withdrawn and tearful and gently explores this.
Midwife intervention: Builds trust and Communication, listens attentively, validating Tahlia’s feelings and reassuring her that it’s normal to have mixed emotions during pregnancy. She encourages Tahlia to talk openly about her concerns with her. Conducts a though assessment, including changes in sleep patterns, appetite, and daily functioning and identifies signs of depression. Provide health education about mental health during pregnancy and explains that untreated depression can affect both Tahlia and her baby. She discusses treatment options, including therapy and medication if necessary, and refers her to a perinatal mental health specialist for further evaluation and support. Continues to check in with her regularly, monitoring her mental health and providing emotional support. She educates Tahlia and her partner about postpartum depression and emphasises the importance of self-care and seeking help if symptoms worsen or new concerns arise.
Outcome: With Anne’s support and the guidance of a perinatal mental health specialist, Tahlia learns coping strategies to manage her depression. She attends therapy sessions and eventually
Challenges and Opportunities in Nursing and Midwifery
Nurses and midwives face several challenges in integrating mental health care into their practice. Limited resources, high patient-to-nurse ratios, and time constraints can impede their ability to provide comprehensive care. However, these challenges also present opportunities for innovation and improvement.
Opportunities for Improvement:
- Education and Training: Enhancing nursing and midwifery curricula to include more extensive training on mental health and its integration into general practice.
- Policy Support: Advocating for policies that support interprofessional collaboration and provide adequate resources for mental health care.
- Community Engagement: Strengthening community-based programs to support mental health awareness and reduce stigma.
Global initiatives like the Nursing Now campaign emphasise the importance of investing in nursing education and leadership, recognising that well-trained nurses and midwives are crucial for achieving health for all.
Reflection Activities
Role-Playing Exercise: Simulate patient interactions where students practice explaining medical conditions and providing emotional support, focusing on clear communication and empathy.
Reflection Questions:
-
- What are additional settings where nurses might work?
- How can a nurse assess if a person’s mental health is at risk?
- Does physical illness always correlate with mental health issues?
- How can language or communication barriers impact mental health in healthcare settings? Review and discuss the provided case studies, identifying key nursing interventions and their impacts on patient outcomes.
- Investigate contemporary issues in mental health nursing and midwifery, presenting findings on innovative practices and emerging trends.
- Explore the biopsychosocial model, discussing its application in real-world scenarios and sharing experiences from clinical placements or previous studies.
References
Australian College of Mental Health Nurses (ACMHN). (2024). What mental health nurses do.
Australian Health Practitioner Regulation Agency (AHPRA). (2024). Australian Health Practitioner Regulation Agency – Home.
Gordon, A., Mikocka-Walus, A., Grzeskowiak, L. E., & Jayasekara, R. S. (2013). Antidepressants for depression during pregnancy. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010710
Kontoyannis, M. (2022). Paternal Post-Natal Depression. Health Science Journal, 16(12), 1.
Mutlu, S., Çetinkaya, A., & Yılmaz, E. (2021). Emergency Service Perceptions and Experiences of Patients: “Not A Great Place But Not Disturbing.” Journal of Patient Experience, 8, 237437352110342–23743735211034298. https://doi.org/10.1177/23743735211034298
Wittink, M. N., Rosenberg, T., Waller, C., Qiu, P., & McDaniel, S. (2022). Real-world implementation of the biopsychosocial approach to healthcare: Pragmatic approaches, success stories, and lessons learned. Frontiers in Psychiatry, 13, 1026415–1026415. https://doi.org/10.3389/fpsyt.2022.1026415
World Health Organization (WHO). (2020). State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-198.
Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L., … & Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32(6), 959-976.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613.
Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney: Psychology Foundation.
Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092-1097.
oyer, E. W., & Shannon, M. (2005). The serotonin syndrome. New England Journal of Medicine, 352(11), 1112-1120.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-198.
Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L., … & Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32(6), 959-976.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613.
Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney: Psychology Foundation.
Newcomer, J. W. (2005). Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs, 19(1), 1-93.
Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092-1097.
Strawn, J. R., Keck, P. E., & Caroff, S. N. (2007). Neuroleptic malignant syndrome. American Journal of Psychiatry, 164(6), 870-876.
