Copyright © eContent Management Pty Ltd. Contemporary Nurse (2010) 34(2): 158–166.

Conceptualising the functional role of

mental health consultation– liaison nurse in
multi-morbidity, using Peplau’s nursing
theory
M
ICHAEL

KM
ERRITT Mental Health Consultation-Liaison Service, Lyell McEwin Health Service, Elizabeth Vale,
SA, Australia N
ICHOLAS

P
ROCTER School of Nursing and Midwifery, University of South Australia, City East Campus, Adelaide,
SA, Australia

ABSTRACT This paper examines the mental health consultation–liaison nursing (MHCLN) role and links
this to the interpersonal relations theory of nurse theorist Hildegard Peplau. The paper argues that, as
mental health nursing care around the world is increasingly focused upon meaningful therapeutic
engagement, the role of the MHCLN is important in helping to reduce distressing symptoms, reduce the
stigma for seeking help for mental health problems and enhancing mental health literacy among
generalist nurses. The paper presents a small case exemplar to demonstrate interpersonal relations
theory as an engagement process, providing patients with methodologies which allow them to work
through the internal dissonance that exists in relation to their adjustment to changes in life roles pre-
cipitated by physical illness. This dissonance can be seen in the emergence of anxiety, depression and
abnormal/psychogenic illness behaviours. This paper concludes arguing for considerable effort being
given to the nurse–patient relationship that allows for the patient having freedom to use strategies that
may help resolve the dissonance that exists.
Keywords: consultation–liaison nursing; interpersonal relations; mental health; Peplau
I I NTRODUCTION

n that contemporary community clinical consultation settings and it is liaison important ser- vices ensure
mental health patients have an active and meaningful voice in their treatment and care planning. This
means ensuring greater emphasis on the valued involvement of patients through dialogue and information
exchange with clini- cians. At the same time there is growing interest
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in the idea that mental health care should be delivered and administered across a range of prac- tice
settings within general health and hospital settings in particular.
It is within the above context that this paper is written. With the collapse of the purpose-built
psychiatric hospital as once the mainstay of tra- ditional mental health care, it is difficult to over
emphasise the importance of community-based C C

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systems and structures as key drivers of contem-
de-personalised by the health system (Barker, porary
mental health care. There is a now a global
2009; Jones, 1998). The emphasis is, in this consensus
that mental health care should be
sense, on the physical, potentially reducing the
undertaken in partnership and collaboration with
patient to a collection of systems and ignoring mental
health patients – no matter where they
the holism and the person or patient’s journey are or
where they live – and in the least restric-
to this point in time. Australian studies have tive
environment (World Psychiatric Association,
shown that whilst depression, anxiety or psy- 2009). At
the same time there is a vision of a
chological distress is identified in patients with seamless
and connected care system which is con-
chronic physical illness, 75% do not receive sumer
focussed and recovery oriented (National
psychological treatment or counselling (Kelly & Mental
Health Policy, 2008).
Turner, 2009). At the same time there is evidence of mar-
Clearly, there is cause for examining the deeper
ginalisation, oppression and incarceration of
structures of engagement in mental health between people
with a mental illness in certain societies
clinicians and patients to advance recovery in (BBC
News, 2009) and in industrialised nations.
mental health. It is for this reason that the authors While
mental disorders represent 15% of the
draw upon the Peplau Model, as the underlying total
disease burden, people with severe men-
theoretical construct used by Hildegard Peplau tal
disorders in low to middle income countries
emphasises the crux of the therapeutic relation- often fail
to receive adequate mental health care
ships as a partnership between the nurse and the (World
Health Organisation/Wonca, 2008).
patient, and with it a notion of shared humanity A recent
UK Health Care Commission report
between the nurse and the patient (Peplau, 1952, (for
example) reveals that of 27,000 people
1991, 1997). Whilst the model has its genesis using
mental health services, 15% said they did
in psychodynamic and psychodramatic theories not have
enough say in care decisions and 44%
giving rise to looking more deeply at the reasons only had
a say to some extent. The Health Care
for individual thought and behaviour (Sullivan,
Commission quizzed 300,000 patients and found
1953), it has been long utilised by mental health that most
wanted more meaningful input into
nurses in clinical practice (Barker, 1993, 2009; their care,
especially those with mental illness.
Price, 1998). Barker (2009) in particular empha- Similar
sentiment has been expressed elsewhere
sised the person rather than the problem to be the in the
UK (BBC News, 2004) and in Australia
focus of mental health nursing. This underlines (Mental
Health Council of Australia, 2006). In
that, according to Peplau, the therapeutic rela- addition
and contrary to recommended national
tionship is a central platform of mental health standards,
less than half of mental health service
nursing practice. Shattell, Starr, and Thomas users
surveyed in the UK had access to crisis care,
(2007) adapted Peplau’s theoretical approach to and only
have had been given or offered a written
described patient’s views of the therapeutic rela- care plan
(Health Care Commission UK, 2008).
tionship as being expressed in three figural themes: Such
conditions are experienced by patients as
‘relate to me’, ‘know me as a person’ and ‘get to
de-humanising and de-personalising, placing
the solution’. The therapeutic relationship is by its
interpersonal relations at the fringe rather than
nature and scope primarily about the creation of a as
central interactions between patient, carer and
shared experience. mental health professional.
The next section outlines steps taken to review People
with co-existing physical and mental
literature pertaining to the functional role of the health
problems are also at risk of marginalisa-
MHCLN informed by Peplau’s nursing theory. tion.
People with chronic physical illnesses also
The utilisation of this theory in multi-morbidity
experience a sense of being de-humanised and
is then discussed.
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Michael K Merritt and Nicholas Procter
M
ETHOD

Roberts, & Taylor, 1997), ‘psychiatric liaison nurs- A

search of electronic data was undertaken using
ing’ (Chiplin & Geraghty, 1990), ‘mental health the
following databases; CINAHL, Medline,
liaison nursing’ and Liaison Mental Health Nursing
PsycINFO and the Cochrane Library. Searches
(Roberts & Whitehead, 2002). The predominant were for
articles published in English and several
terminology is ‘psychiatric consultation–liaison search
themes were used as follows:
nurse’ which is a naturalistic outcome of the growth
• Australian and International literature since
of these positions out of psychiatric consultation– 1990
about Mental Health Consultation–
liaison services and the biological-psychiatry Liaison
Nursing using a variety of descriptors –
model. These terms are used both simultaneously see
Tunmore and Thomas (1992). 1990 was
and interchangeably to describe the work of men- used as a
starting point and can be considered
tal health nurses within a general hospital setting. a focal
point in the transition from asylum
The fluidity of this terminology can be seen as to
community care within South Australia.
an outcome of the underlying dichotomy that Australian
literature was used to provide his-
exists within the mental health nursing profession torical
and current context of practice, whilst
around the world. Barker (2009, p. 5) argues that
international literature was used to look for dif-
mental health nurses including MHCLNs work ferences in
operationalisation of MHCLN prac-
within a highly fluid continuum between psychi- tice,
which may have informed or influenced
atric nursing and mental health nursing, and thus the
Australian context of practice. Some early
between problem- or situation-focused and holism
Australian literature from the 1980s provides a
or life-focused. firmer historical context.
In the 1980s Meredith and Weatherhead
• Literature by Hildegard Peplau and others
(1980), Anderson and Hicks (1986) and Hicks describing
interpersonal relations theory.
(1989) described early roles in Sydney, Australia.
• Literature about utilisation of interpersonal
This early literature described a traditional relations theory
in psychiatric-mental health
structure in the style of Caplan (1964, 1970) nursing
practice.
in Tunmore and Thomas (1992), that has its
• Literature about multi-morbidity and psycho-
roots in the work of psychosomatic medicine as logical
outcomes.
described by Lipowski (1981). The literature since 1997 describes two different models; that of the
Additional exploration was conducted by hand
traditional consultation–liaison nursing model utilising
reference lists from retrieved articles.
(Sharrock & Happell, 2000, 2001a, 2001b), and

T
HE MENTAL HEALTH CONSULTATION

–
an emerging emergency mental health nursing model within emergency departments (Wand, LIAISON
NURSE
 2004; Wand & Happell, 2001) alternatively The MHCLN
has become an established part
called the ‘emergency department mental health of
contemporary nursing in Australia (Sharrock,
team’. These roles show the advanced mental Grigg,
Happell, Keeble-Devlin, & Jennings,
health nursing development that has been accel- 2006),
the United Kingdom (Cullum, Tucker,
erating in recent years with some of these roles Todd, &
Brayne, 2007), Canada (Brinkman,
being developed into ‘mental health nurse prac- Hunks,
Bruggencate, & Clelland, 2009) and
titioner’ positions (Wand, White, & Patching, United
States (Yakimo, Kurlowicz, & Murray,
2007). Further, McNamara, Bryant, Forster, 2004). The
role is variously described as ‘psy-
Sharrock, and Happell (2008) and Sharrock, chiatric
consultation–liaison nursing’ (Sharrock
Bryant, McNamara, Forster, and Happell (2008) &
Happell, 2000; Yakimo et al., 2004), ‘liaison
describe the outcomes of a survey of CL nurses
psychiatric nursing’ (Cullum et al., 2007; Ryrie,
within Australia, which provides valuable data
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about demographics, role description, prepara-
patient uses these strategies to provide a reduc- tion,
support and role satisfaction of these mental
tion of or resolution of the internal dissonance/ health
nurses. These show the developments that
psychological distress. have impacted upon the role
unfolding elsewhere
Within the development of the nurse– patient across
Australia.
or therapeutic relationship, the MHCLN provides many roles. Peplau emphasised six of T
HEORETICAL UNDERPINNINGS OF
these roles: MENTAL HEALTH NURSING MODEL

• Stranger role – developing an accepting climate

Peplau theorised that people have biological,
to build interpersonal trust similar to that used
psychological and social qualities which moti-
in other life situations vate them to self-maintenance,
and that their
• Resource role – providing and exchanging infor-
self-system is concerned with the management of
mation and interpreting clinical data anxiety. When this
self-maintenance/self-system
• Teaching role – providing instruction and train- is in
disequilibrium, this gives rise to an internal
ing through analysis and synthesis of patient’s
dissonance which manifests itself in panic, with-
experience drawal and an inability to function
effectively.
• Counseling role – providing an environment This can
also be more broadly understood in
where patient can understand and integrate the signs and
symptoms which we understand
their current life experience along with guid- as
depression, anxiety, psychosis and abnormal/
ance and encouragement to develop and experi-
psychogenic illness behaviours. Peplau clearly
ence change identified that both biological and
psychological
• Surrogate role – through advocacy, the nurse
insecurities can lead to or create internal disso-
assists the patient’s clarification of their nance or
anxiety.
dependent, interdependent and independent Within the
model are two components – the
domains phases of the therapeutic relationship and the
• Leadership role – the nurse provides an envi- dynamic
character roles seen as typical of mental
ronment where patients assume responsibility health
clinical nursing.
for reaching their treatment goals and therefore Peplau
described four interlocking and over-
optimal functioning lapping phases of the nurse–patient
relationship:
• Technical/clinical expert role – the nurse pro-
• Orientation phase
vides an environment for holistic patient care
• Identification phase
through utilisation of clinical skills
• Exploitation phase
• Resolution phase
 Actual or specific roles utilised within the ther- apeutic relationship will be variable between The
orientation phase is synonymous with
patients and the overall skill/expertise and imagi- the
comprehensive assessments conducted by
nation of the MHCLN. MHCLN in understanding or
appreciating
The nurse–patient or therapeutic relation- how the
patient arrived at the point in time
ship becomes a transitional conduit that shifts where the
MHCLN is involved in their care
the perspective from a problem focus that exists and
support. The identification and exploita-
both within biological-psychiatry and the nursing tion
phases are the working phases where the
process (problem orientation) towards holism and
MHCLN supports the patient in identification
the patient as a person and their life experience. of the
internal dissonance and development
This notion of the patient’s self identification of and
trialling of strategies that reduce the inter-
what experience and symptoms mean for them nal
dissonance. The final phase is where the
becomes a framework for thoughts, feelings and
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Michael K Merritt and Nicholas Procter
actions to be understood using the language and
to Emergency Departments and that total health
experience of the patient.
expenditure can be 4.5-times higher for these The utility of
this model has been in the cre-
individuals. Further, they can have longer hospi- ation of
a therapeutic relationship that allows for
talisations, increased symptom burden and higher the
identification of anxiety, depression and other
mortality and morbidity outcomes. An integral
psychogenic symptomatology by the patient in
part of this burden is associated with a worsening the
supportive environment provided by the
quality of life. The importance of the appropriate
MHCLN, and then the patient having freedom
psychological care of medical patients has been to use
strategies that may help resolve the disso-
emphasised by a report from the joint working nance that
exists. The overall aim is in a directive
party of the Royal College of Physicians and the approach
in which there is a ‘forward movement
Royal College of Psychiatrists (2003). of personality in
the direction of creative, con-
Recent Australian Institute of Health and Welfare
structive, productive, personal and community
(2008) data suggests that chronic respiratory illness
living’ (Peplau in Gastmans, 1998).
affects 4.3% of people aged 20–44 and 8% aged over 65. Chronic heart disease affects 7.3% of those A
FOCUS FOR MENTAL HEALTH

aged 55–64 and rising to 20.3% of those aged 75

CONSULTATION
–
LIAISON NURSING

and over. MacHale (2002) states that the incidence The

above synthesis leads to a role definition
of depression in those patients with diabetes, car- of the
MHCLN as having a focus on the bio-
diac or neurological disease is about 25%, whilst the
psycho-socio-spiritual, cognitive, behavioural,
incidence for those with hypertensive disorders is and
emotional responses of patients and families.
equivalent to the general population, and in addi- The
MHCN assists patients, family, staff, and
tion, in-patients are more vulnerable than outpa- health
systems cope with medical illness, treat-
tients. The prevalence of chronic mental health ment and
the often consequential psychologi-
disease is put as high as 11% of the general popula- cal
distress/internal dissonance experienced by
tion and that at least 40% of these individuals have
patients. The role of the MHCLN in this setting
at least one co-morbid physical illness. Further the
ensures that the patient’s overall needs are met,
rates of chronic physical illness are between 30–80% and
that patients, families and staff satisfaction is
above that for the general population. increased.
In the next section the MHCLN will be exam- The World
Health Organisation’s proposition
ined through a short vignette. The vignette out- that there
can be ‘no health without mental health’
lines assessment and support for a person within (Prince
et al., 2007) has important implications
the continuum from hospital to community where for
MHCLN practice. Global burden of disease
no other service is available. Peplau’s model will data
suggests that the world-wide burden for non-
be demonstrated as being versatile and adaptable
communicable diseases (such as endocrine, car-
enough to be readily applied to people with acute, diac
and mental health) was 48.9% in 2005 and
acute-on-chronic or chronic physical diseases. is
projected to rise to 56.9% by 2030. In 2005 the neuropsychiatric disorders component of this

V
IGNETTE was 28%. A report by the Academy of
Medical
Jason1 was a 62-year-old man referred to the Royal
Colleges (AMRC) and Royal College of
MHCLN led clinic by a Cardiac Rehabilitation
Psychiatrists (RCP) (2009) indicates that patients
Nurse for assessment of depression and anxiety with
chronic diseases and a mental health disorder
after being admitted with angina. Jason and his such as
depression were twice as likely to present
wife Maxine had been touring remote and outback
1 Not his real name.
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South Australia in a mobile home at time of his latest
Jason and his son had similar personality styles and
angina attack. They had been pursuing this lifestyle
problem solving methodologies – which followed of
roving and rambling for the past 10 years. He
a need to fix things and do it my way fashion – this was
initially medically assessed in hospital, where he
was also corroborated by Maxine who was included
reported a change in his sense of self, a feeling of
in all follow-up sessions. Over several one-to-one loss of
control and a general nervousness and inabil-
sessions with the MHCLN, Jason identified ways ity to
make decisions with a negative outlook on
of improving his relation with his son by exploring future
and a reduction in his quality of life. Further
different problem solving techniques – some of he
reported preoccupation with issues, increased
this through role play. Maxine was also provided
worrying, poor sleep and feeling ‘anxious, nervous
with support and encouraged to voice her own and edgy’.
His wife agreed with this self assessment,
anxieties around recent events and how she saw and both
felt that there ‘was no depression’, more
Jason’s progress. an ‘adjustment to life issues’. Further
assessment
At finish of follow-up, Jason and Maxine revealed that
Jason had recently had an argument
reported the resolution of anxiety provoking issues with
his son about his grandson’s birthday party
that had been identified and explored above, and which
had increased his anxiety and distress.
were just waiting for clearance from the cardiolo- The
MHCLN met with Jason. The conversa-
gist to resume their travelling. In using Peplau’s tion
focused on Jason’s reported anxiety feelings
theory, the MHCLN had fulfilled many roles and
provided education in verbal and written
including stranger, resource, teacher, counsellor, formats
about anxiety, causation and perpetuat-
surrogate, companion, advocate and leader in the ing
factors using his symptoms and self-story as
development, establishment and continuation guideposts.
Through further exploration of recent
to resolution of the nurse–patient or therapeutic events,
Jason identified three main areas which
relationship. The focus was on developing a shared
underlay his anxiety – his cardiac condition and
experience where the client was the centre of focus newly
diagnosed aortic regurgitation and cardio-
and maintained control of the relationship. The myopathy,
loss of control of and interruption of
ability for the MHCLN to provide support in current
lifestyle and relationship issues with his
both hospital and community settings, expands son. The
ability of Jason to identify the underly-
the vision of the role and provides a broader scope ing
causes for his anxiety/nervousness had a clear
for continuity of care, especially where services effect on
his outlook regarding current situation,
may not exist and where patients do not meet with the
development of a more positive outlook
entry criteria into existing community mental about the
future. Further follow-up appointments
health services. McNaughton (2005) highlighted were
organised at the caravan park they were stay-
the naturalistic use of Peplau’s theory in home vis- ing so
ongoing monitoring could be put in place
iting/community follow-up of patients. and future surgery
could be organised.
The MHCLN provided information and edu- Follow-up
in the community lasted 5 months
cation to ward and cardiac rehabilitation nursing until
after surgery. The MHCLN worked with
staff around Jason’s anxiety/internal dissonance Jason on
identified problems, providing further
and strategies in identification, exploration and education
and support regarding surgery and
supporting patient’s experiences. Through this outcomes
in conjunction with specialist cardiac
process, the MHCLN was able to support the
rehabilitation nurses, which included a likely time
patient’s transition through primary, secondary frame in
which he and Maxine could continue their
and tertiary healthcare systems through specialist lifestyle
and therefore the transition to being more
advocacy, collaboration and liaison with nursing, in
control of life. During exploration of relation-
medical and other allied health specialists as well ship
issues with son, it soon became apparent that
as the patient’s primary care general practitioner.
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Michael K Merritt and Nicholas Procter
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LINICAL LEADERSHIP

providing patients with methodologies which allow At the

interface between physical and mental health
them to work through the psychological distress/ the
MHCLN is well situated to establish links and
internal dissonance that exists in relation to their
partnerships of an enduring nature between allied
adjustment to changes in life roles precipitated by health
providers, patients, patient advocacy groups,
physical illness. This dissonance can be seen from
families and carers to develop a culture of enhanc-
a biological-psychiatry model in the emergence of ing
collaborative care and mental health literacy.
anxiety, depression and abnormal/psychogenic illness
This model gives rise to Servant Leadership – a
behaviours. In the sharing of the patient’s journey of
relatively recent concept in the literature on lead-
discovery, the MHCLN acts as a fellow traveller, a ership
styles. ‘A servant leader serves constituents
guide and companion and in some instances a lexi- by
working on their behalf to help them achieve
con that allows the patient to give a name to the dis- their
goals, not simply the leader’s goals’ (DuBrin,
sonance that they are experiencing. The emphasise
Dalglish, & Miller, 2006, p. 69). Servant leader-
of this working along-side the person experiencing ship in
mental health is accomplished when clini-
mental distress to establish a meaning that best fits cians
and colleagues become wiser, empowered and
her/his experience has been underpinned by Crowe, more
autonomous. Servant leadership emphasises
Carlyle, and Farmar (2008). the leader’s role as host,
facilitator and enabler of
In modern healthcare systems, patients often the
resources (human, financial, educational and
spend little time in hospital once the acute phase of
otherwise) needed to ensure a positive clinical out-
their physical illness is has passed. This has as much
come for an individual, group or community. It
to do with improved community care aligned with
encourages leaders to demonstrate humility, have
evidence-based medical and nursing interventions,
mindfulness in what they say, do think and feel
increasing demands on hospital systems, public sec- while
staying simultaneously focused on achiev-
tor Medicare/insurance reimbursement, primary ing
results in line with the agreed directions and
health care initiatives and the development of a vari-
organisation’s values and integrity.
ety of government and non-government community As a
clinical servant leader, the MHCLN is a
support services. Given this, the full utilisation of
partnership broker, participating in and leading
Peplau’s theory needs to occur across the care spec-
change in the workplace. This change can be for-
trum – in both hospital and community settings. malised
into professional administrative policies to
The ability for the MHCLN to work across clinical
facilitate access to intervention services across the
settings is important for patients to be able to reduce
health spectrum. Through this work there is scope
and/or resolve their psychological distress/internal to
influence the role and function of how health
dissonance where no other service is available. services
are delivered at local, state and national
As such the MHCLN may not know enough of
government levels to build social connectedness
the impact that their role has upon patients, carers and
social inclusion for people with mental health
and health professional colleagues. This highlights
problems and their carers. The MHCLN is, in this
the need for the MHCLN to initiate and conduct sense a
‘leader as connector’ who actively promotes
clinically focused research on early intervention clinical
continuity and collaboration with special-
strategies of clinical assessment, engagement ist health
services and advocates for adequate ser-
and treatment of mental health problems. There vices for
people with mental health problems at
is scope for this research to be interdisciplinary both
patient and systemic levels.
incorporating both qualitative and quantitative

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ONCLUSION

measures specifically addressing phase specific treatments and strategies for the patient’s narrative
Peplau’s interpersonal relations theory is by its nature
to unfold. The emphasis of research should there- and
scope an engagement process that is about
fore be applied and interventionist to help ensure
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that the MHCLN is an enabler of interventions
depression: A randomized control trial. Age and to
prevent secondary disability associated with
Ageing, 36(4), 436–442. physical or mental health
problems. Over time the MHCLN can make informed evidence- based clinical decisions by ensuring that
previous research is critically reviewed and integrated into decision making and clinical education.

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Received 04 February 2009 Accepted 21 October 2009
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