‘Judging’ mental health nursing

1 May 2014

MARK SMITH of Te Pou puts the case for using ‘outcomes’ to judge ‘success’ in mental health nursing.

MARK SMITH of Te Pou puts the case for using ‘outcomes’ to judge ‘success’ in mental health nurMARK SMITH of Te Pou puts the case for using ‘outcomes’ to judge ‘success’ in mental health nursing.

‘Passing judgement’, being ‘judgemental’, ‘judging the worth of something’ are terms that elicit fear, consternation, and anxiety.

“How dare they judge me?” is how the thinking goes. And “who do they think they are to pass judgement?” inevitably follows.

Yet judge we do, whether we like it or not. We can’t stop ourselves. In terms of mental health services, I often wonder what criteria we use to pass judgement? There are lots of ways we could pass judgement: counting the number of staff employed by mental health services (an example of an input-based judgement) or counting the number of people seen (an example of an output-based judgement). But how do we judge what makes for a good mental health service?

Until recently in New Zealand, inputs or outputs have generally been the favoured approach. However, outcomes may well be a better and fairer way of judging services. That is we may have inputs (money, resources, and staff) that generate lots of outputs (people seen, number of contacts, bed nights etc.) but to what effect? Outcomes can help answer this question.

New Zealand has decided to develop an outcomes-focused mental health and addiction service. This approach to workforce development shows how outcomes and other indicators can be collected and used at both the individual and aggregated level.

New Zealand has mandated using the HoNOS family of measures (see box). At the individual level outcomes can assist service users to set goals for their own recovery which can help them to recover more quickly.

Clinicians are often buried under a considerable burden of information. Not all of it is equally important. A clinician who is more efficient and focused through their emphasis upon outcomes will have more time to devote to their core role.

A personal note

Outcome measurement has played an important role in my own career. As an applicant for nurse practitioner registration in 2002, the Nursing Council – not unreasonably – wanted to know what evidence there was I was making a difference in my proposed new role.

That role involved working as a nurse practitioner with young people at risk of self harm or suicide after being discharged from an inpatient unit. I found myself turning to HoNOS and HoNOSCA as a way of indicating the difference I was making. Though this didn’t always show positive change, it indicated that changes were happening in people’s outcomes. While not all these changes could be attributed to the work I was doing, it did provide an indicator of my contribution. This certainly helped with my Nursing Council application, and subsequent to getting my NP registration, it helped establish my role with collegues.

While in my own clinical role I have found it useful to collect and use outcome measurement scores, I realise that there remains some scepticism in the sector about their usefulness. It is for this reason that I want to indicate what some of the clinical uses can be.

Overcoming outcome sceptics

While outcome scores will be sent onto the Ministry of Health to become part of the national collection, many clinicians don’t get any aggregated reports back and wonder about their utility. However, in practice clinicians can use outcome measurement for a number of purposes at the individual level:

Feeding back outcome scores to service users can help establish the therapeutic alliance and the rapport of the relationship.

Developing plans based on the outcome scores can be a useful way of ensuring outcome scores, plans and clinical notes are all synchronised.

Outcome scores can be a useful way of allocating referrals since they provide a way of determining the severity of presentations rather than simply relying on numbers.

They can be a helpful way of determining when to discharge people, giving permission to discharge if someone repeatedly scores 0s and 1s.

There are numerous aggregated uses for outcome measurement for reporting at team, DHB, and national level that can help with benchmarking services and identifying trends and patterns over time.

Stop Press: new measure for addiction services

The ministry has signalled its intention to mandate the ADOM (alcohol and drug outcome measure) from July 2015 for addiction services. This will mean that the HoNOS family of measures for mental health services and the ADOM for addiction services will be two mandated outcome measures.

As the only currently mandated, routinely collected outcome measures in mental health services, the HoNOS family of measures provides one way of judging services. While we would never advocate using these measures to pass judgement in isolation, when combined with other indicators, they do provide a useful way of judging performance. 

Author: Mark Smith RN NP PhD is clinical lead for mental health and addiction workforce agency Te Pou.


What is HoNOS?

HoNOS stands for Health of the Nation Outcome Scale. It collects information about a person’s mental health and social functionioning across 12 areas – eg. behaviour, delusions/hallucinations, and social problems and gives them a score of 0-4 (a score of 0 indicates no problem and 4 indicating a severe problem). The measurement scale was developed for people with severe mental illnesss by UK’s Royal College of Psychiatrists in the mid-1990s at the request of the UK Department of Health.

In New Zealand, HoNOS is used as the standard measure of mental health outcomes across mental health services. HoNOS scores are usually initially collected at admission to an acute mental health service, reviewed after three months and then periodically until discharge. Outcomes are calculated by the change in the HoNOS scores