Proposed nurse-led initiatives in improving physical health of people with serious mental illness: a survey of nurses in mental health

Healthcare Professional Perspectives on the Impact of the Physical Health Nurse Consultant

Early mortality experienced by people living with mental health issues (hereon termed consumers) is largely preventable. Healthcare professionals perceive healthcare system inadequacies such as diagnostic overshadowing, stigma and fragmentation of physical and mental healthcare services can be resolved through effective integration approaches. Service- and individual-level integration approaches involve multidisciplinary teams collaborating and coordinating care to holistically meet consumers' physical and mental health needs. Evidence suggests appropriately trained healthcare professionals can deliver effective integrated treatment without financial or organisational restructuring. Specialist nursing positions such as Physical Health Nurse Consultants can support and integrate physical and mental health care. Consumers report the Physical Health Nurse Consultant as providing dedicated, integrated, coordinated and holistic mental and physical health care. This study aimed to explore the Physical Health Nurse Consultant role from the perspectives of healthcare professionals. A qualitative exploratory study design was used. Fourteen healthcare professionals participated in individual interviews or focus groups. Interview recordings were transcribed, and thematically analysed. Three themes were identified: (i) role functions, including integration of physical and mental health care, (ii) impact on consumer physical health outcomes and (iii) impact on service delivery. Healthcare professionals perceive the Physical Health Nurse Consultant effectively integrates physical and mental health care and subsequently support the continuation and embedding of the role in routine practice. Future research is required to explore healthcare professionals' experiences and perceptions of how these roles be translated to routine clinical practice. Examining the professional development requirements, service provider constraints and economic implication to achieve these outcomes also warrants attention.

Monitoring Persons' Rights to Equal Care: Registered Nurses' Experiences of Caring for People with Mental Ill-Health and Somatic Comorbidity in Psychiatric Outpatient Care

Persons with severe mental ill-health die early from preventable physical ill-health. Registered nurses in psychiatric outpatient care play a key role in improving persons' physical health, and it is important to examine how they view their responsibility, their experiences of care, and the obstacles they meet in providing person-centred care. The purpose of this study was to explore registered nurses' experiences of caring for persons with mental ill-health and somatic comorbidity in psychiatric outpatient care, using qualitative content analysis to analyze data from semi-structured interviews. The results show that these nurses monitored the person's right to equal care, embraced the whole of the persons suffering, and dealt with unclear boundaries in care. This highlights the unique role that registered nurses play in psychiatric outpatient care via their ability to interpret symptoms and find ways to adapt care based on persons' needs. Registered nurses consider physical health in all care and provide a link between psychiatric and somatic care. Together with mental health nurses at primary health care centers, they are key in reducing persons' suffering. There is a need for structural and functional changes in line with person-centred care including collaboration both within and outside healthcare organizations.

The role of trust and hope in antipsychotic medication reviews between GPs and service users a realist review

BACKGROUND

Increasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support.

AIM

To explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input.

DESIGN & SETTING

Realist review in general practice settings.

METHOD

A realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews.

RESULTS

Meaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory.

CONCLUSIONS

The review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.

An economic evaluation of a specialist preventive care clinician in a community mental health service: a randomised controlled trial

BACKGROUND

Clinical practice guidelines and policies direct community mental health services to provide preventive care to address chronic disease risks, however, such care is infrequently provided in routine consultations. An alternative model of care is to appoint a clinician to the dedicated role of offering and providing preventive care in an additional consultation: the 'specialist clinician' model. Economic evaluations of models of care are needed to determine the cost of adhering to guidelines and policies, and to inform pragmatic service delivery decisions. This study is an economic evaluation of the specialist clinician model; designed to achieve policy concordant preventive care delivery.

METHODS

A retrospective analysis of the incremental costs, cost-effectiveness, and budget impact of a 'specialist preventive care clinician' (an occupational therapist) was conducted in a randomised controlled trial, where participants were randomised to receive usual care; or usual care plus the offer of an additional preventive care consultation with the specialist clinician. The study outcome was client acceptance of referrals to two free telephone-based chronic disease prevention services. This is a key care delivery outcome mandated by the local health district policy of the service. The base case analysis assumed the mental health service cost perspective. A budget impact analysis determined the annual budget required to implement the model of care for all clients of the community mental health service over 5 years.

RESULTS

There was a significantly greater increase from baseline to follow-up in the proportion of intervention participants accepting referrals to both telephone services, compared to usual care. The incremental cost-effectiveness ratio was $347 per additional acceptance of a referral (CI: $263-$494). The annual budget required to implement the model of care for all prospective clients was projected to be $711,446 over 5-years; resulting in 2616 accepted referrals.

CONCLUSIONS

The evaluation provides key information regarding the costs for the mental health service to adhere to policy targets, indicating the model of care involved a low per client cost whilst increasing key preventive care delivery outcomes. Additional modelling is required to further explore its economic benefits.

TRIAL REGISTRATION

ACTRN12616001519448. Registered 3 November 2016, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371709.

Health Effects of an Individualized Lifestyle Intervention for People with Psychotic Disorders in Psychiatric Outpatient Services: A Two Year Follow-up

People with psychotic disorders experience to a great extent avoidable physical illnesses and early mortality. The aim of the study was to investigate the potential effects for this group of participating in a lifestyle intervention. A multi-component nurse-led lifestyle intervention using quasi-experimental design was performed. Changes in biomedical and clinical measurements, self-reported health, symptoms of illness and health behavior were investigated. Multilevel modeling was used to statistically test differences in changes over time. Statistically significant changes were found in physical activity, HbA1c and waist circumference. A lifestyle intervention for people with severe mental illness can be beneficial for increasing physical activity.

Mental health professionals' views and experiences of antipsychotic reduction and discontinuation

BACKGROUND

The widely established treatment for psychosis is long-term antipsychotic medication. However, many people stop taking this treatment, and request other options. There are also growing concerns about adverse effects, but currently no professional guidelines to support reducing or stopping these drugs. The views and experiences of individual mental health professionals around reducing and stopping antipsychotics are therefore crucial in treatment decisions.

METHODS

We conducted 7 focus groups with prescribing psychiatrists and other members of community-based statutory mental health services in London. Participants discussed their views about, experiences, and processes of antipsychotic reduction and discontinuation. Data were analysed using thematic analysis.

RESULTS

Participants acknowledged that antipsychotics can have severe adverse effects. They were generally supportive of trying to reduce these drugs to the lowest effective dose, although stopping antipsychotics was less acceptable. Prior experiences of adverse events after reduction or discontinuation meant that both were approached with caution. Reduction was also reported to be hampered by organisational and knowledge barriers. Lack of resources, pressure to discharge, and poor continuity of care were seen as organisational barriers. Knowledge barriers included inadequate evidence about who might be best suited to reduction, and lack of guidance about how this could be done safely. This meant that reduction was often prompted by patients, and sometimes actively discouraged, and stability with maintenance treatment was often favoured.

CONCLUSIONS

Concerns about risk and other barriers means that clinicians are often reluctant to implement reduction or discontinuation of antipsychotic medication. In order to increase the treatment options available to service users, more research and guidance on how to minimise the risks of antipsychotic reduction and discontinuation is required to enable clinicians to engage more constructively with service users requests, offering people more choice and control in managing their mental health condition.

Mental health nurses' attitudes, experience, and knowledge regarding routine physical healthcare: systematic, integrative review of studies involving 7,549 nurses working in mental health settings

Background

There has been a recent growth in research addressing mental health nurses’ routine physical healthcare knowledge and attitudes. We aimed to systematically review the empirical evidence about i) mental health nurses’ knowledge, attitudes, and experiences of physical healthcare for mental health patients, and ii) the effectiveness of any interventions to improve these aspects of their work.

Methods

Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple electronic databases were searched using comprehensive terms. Inclusion criteria: English language papers recounting empirical studies about: i) mental health nurses’ routine physical healthcare-related knowledge, skills, experience, attitudes, or training needs; and ii) the effectiveness of interventions to improve any outcome related to mental health nurses’ delivery of routine physical health care for mental health patients. Effect sizes from intervention studies were extracted or calculated where there was sufficient information. An integrative, narrative synthesis of study findings was conducted.

Results

Fifty-one papers covering studies from 41 unique samples including 7549 mental health nurses in 14 countries met inclusion criteria. Forty-two (82.4%) papers were published since 2010. Eleven were intervention studies; 40 were cross-sectional. Observational and qualitative studies were generally of good quality and establish a baseline picture of the issue. Intervention studies were prone to bias due to lack of randomisation and control groups but produced some large effect sizes for targeted education innovations. Comparisons of international data from studies using the Physical Health Attitudes Scale for Mental Health Nursing revealed differences across the world which may have implications for different models of student nurse preparation.

Conclusions

Mental health nurses’ ability and increasing enthusiasm for routine physical healthcare has been highlighted in recent years. Contemporary literature provides a base for future research which must now concentrate on determining the effectiveness of nurse preparation for providing physical health care for people with mental disorder, determining the appropriate content for such preparation, and evaluating the effectiveness both in terms of nurse and patient- related outcomes. At the same time, developments are needed which are congruent with the needs and wants of patients.

Electronic supplementary material

The online version of this article (10.1186/s12912-019-0339-x) contains supplementary material, which is available to authorized users.

Mental health care professionals' accounts of actions and responsibilities related to managing physical health among people with severe mental illness

BACKGROUND

Life expectancy of people with severe mental illness (SMI) is greatly shortened compared to the general population, and despite extensive research, this issue is unsolved. Although it is widely recognised that people with SMI need support from health care services to manage health related issues, profound health inequalities exist within provision of health care. The aim of this study was to examine how mental health care professionals accounted for their actions and responsibilities related to managing physical health issues among people with SMI.

METHODS

Three focus groups were conducted with 22 mental health care professionals, employed at three mental health care locations. Participants' situated accounts were subjected to discourse analysis.

RESULTS

Participants accounted for actions and responsibilities in three typical ways; 1) by positioning people with SMI as difficult to motivate and actively resisting intervention, 2) by positioning people with SMI as so impaired that intervention was futile, and 3) by arguing they are undertreated for physical conditions and might have physical illnesses that staff are not aware of because of prominent mental illness. These discursive strategies seemed to legitimise situations where participants described not responding to physical health issues, and to downplay potential trouble in situations where participants described not succeeding in facilitating lifestyle changes or promoting compliance to treatment of physical conditions.

DISCUSSION AND CONCLUSION

Mental health care professionals need to increase their awareness of latent discriminating attitudes towards people with SMI. Such attitudes are suggested to reinforce barriers for people with SMI receiving physical health care.

What Is the Impact of Targeted Health Education for Mental Health Nurses in the Provision of Physical Health Care? An Integrated Literature Review

Individuals with a severe mental illness have a gap in life expectancy of up to 20 years in comparison to the general population. Nurses who work in mental health services have been identified as best placed to improve the physical health outcomes of individuals with mental illness. The literature identifies a lack of nursing knowledge related to physical health care and the presence of metabolic syndrome which is impeding nurses in providing essential physical health care to patients. An integrated literature review was carried out due to the dearth of research evidence pertaining to the impact of targeted education specifically with psychiatric/mental health nurses in the provision of physical healthcare. A search for literature included the following databases: CINAHL, Medline, PsycINFO, Embase and Web of Science revealed nine studies: seven quantitative, one qualitative and one mixed method. Qualitative synthesis has shed light on the value of targeted education on improving knowledge and skills in providing physical health care that can then be translated into clinical practice. Targeted education in physical healthcare grows psychiatric/mental health nurse's confidence and develops the skills necessary to enable them to screen and monitor and offer range of physical health interventions to individuals with severe mental illness. Accessible summary • The poor physical health outcomes and premature death of individuals with severe mental illness is of growing concern; a contributing factor is a lack of knowledge and confidence amongst psychiatric/mental health nurses to providing physical health screening and intervening in preventable diseases such as cardiovascular disease, stroke cancer, and type 2 diabetes mellitus. • An integrated literature review was used to ascertain if targeted education on physical health care can improve the knowledge base of psychiatric/mental health nurses within physical health care. • Nine studies were critically appraised, and the data reduced using a narrative synthesis that tells a story of the findings from these research studies. • The review found that targeted education with psychiatric/mental health nurses does result in a statistical increase in knowledge This review finds that nurses have not been regularly supported with physical health education to alter existing practices. This lack of knowledge within physical healthcare is hindering psychiatric/mental health nurses to fully engaging in physical health care activities in practice.

Who is responsible for metabolic screening for mental health clients taking antipsychotic medications?

Metabolic syndrome is common in mental health consumer populations, and is linked to cardiovascular disease, stroke and diabetes. Metabolic screening is a way of recognising consumers who are at risk of developing metabolic syndrome but internationally screening rates remain low. A retrospective audit was completed at one Australian public mental health service on the case files of 100 randomly selected consumers to determine nurses level of compliance with metabolic screening policies over a 12 month period. Consumers included in the review were prescribed antipsychotic medications for at least 12 months and had their care in the community coordinated by mental health nurses. Data were entered into an Excel spreadsheet for analysis. Low levels of metabolic screening were identified and these levels decreased over the 12 months under review. No consumers had metabolic screening that recorded all parameters at three monthly intervals over the 12 month period. Only one consumer had every metabolic parameter recorded on the physical health screen tool at baseline assessment. The findings demonstrated that while there is increased awareness of co-morbid physical health issues in this consumer population, the translation of guidelines and policy directives to clinical practice to address this disparity remains low. Improving physical health outcomes is the responsibility of all health professionals, particularly doctors who prescribe and nurses who administer antipsychotic medications regularly to mental health consumers. Moreover, nurses are well placed to demonstrate leadership in reducing the rate of metabolic syndrome through the delivery of holistic care that includes effective screening programs.

Master's level mental health nursing competencies, a prerequisite for equal health among service users in mental health care

PURPOSE

This discussion paper aims to explore the need of a clarified definition of master's level mental health nursing competencies in terms of knowledge, skills and attitudes in a European context. Mental health service users have, in spite of their right to equal overall health, higher rates of physical illness and are more likely to experience premature death than the general population. Implementation of a holistic concept of health comprising mental, physical and social aspects of health in mental health services has previously proved to be challenging.

METHODS

Master's level mental health nursing competencies in recent literature are discussed and illuminated in terms of knowledge, skills and attitudes in order to enable the promotion of equal overall health among service users in mental health services.

RESULTS

The discussion show contents, values and utility of master's level mental health nursing competencies in mental health services and contribute to reduced role ambiguity by distinguishing master's level responsibilities from undergraduate nursing tasks and obligations of other professionals in mental health care.

CONCLUSION

This discussion paper shapes implications for developments in master's level mental health nursing education curricula.

The Validity and Reliability Characteristics of the M-BACK Questionnaire to Assess the Barriers, Attitudes, Confidence, and Knowledge of Mental Health Staff Regarding Metabolic Health of Mental Health Service Users

Background

Addressing the burden of poor physical health and the subsequent gap in life expectancy experienced by people with mental illness is a major priority in mental health services. To equip mental health staff with the competence to deliver evidence-based interventions, targeted staff training regarding metabolic health is required. In order to evaluate the effectiveness of staff training regarding metabolic health, we aimed to develop a succinct measure to determine the barriers, attitudes, confidence, and knowledge of health practitioners through the development and test–retest reliability of the Metabolic-Barriers, Attitudes, Confidence, and Knowledge Questionnaire (M-BACK).

Methods

The M-BACK questionnaire was developed to evaluate the impact of specialized training in metabolic health care for mental health nurses. Content of the M-BACK was developed from a literature review and refined by an expert review panel and validated via a piloting process. To determine the test–retest reliability of the M-BACK, 31 nursing students recruited from the University of Notre Dame, Sydney completed the questionnaire on two separate occasions, 7 days apart. Intraclass correlation coefficients (ICCs) were calculated for the total score, as well as each of the four domains.

Results

Pilot testing was undertaken with a sample of 106 mental health nurses with a mean age 48.2, ranging from 24 to 63 years of age, who participated in six training courses. Questionnaire development resulted in a 16-item instrument, with each item is scored on a five-point Likert scale ranging from “strongly disagree” to “strongly agree.” Test–retest reliability of the M-BACK was completed by 30 of 31 nursing students recruited, ICCs ranged from 0.62 to 0.96.

Conclusion

The M-BACK is a reliable measure of the key elements of practitioner perceptions of barriers, and their knowledge, attitudes, and confidence regarding metabolic monitoring in people with mental illness. It can be used to assess the effectiveness of interventions aimed at increasing uptake of metabolic monitoring, a key component of programs to reduce the life expectancy gap in people living with severe mental illness.

Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care

The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.

Nurse Practitioner Mental Health Care in the Primary Context: A Californian Case Study

In America, mental health needs surpass the availability of specialized providers. This vulnerable population also has other obstacles for comprehensive care including gaps in medical coverage, stigma, economic barriers, and a geographical mal-distribution of qualified mental health professionals. A wide availability of primary care providers, including primary care and family nurse practitioners, are well-positioned to deliver integrated mental and physical health care. A case study from a Southern California Coachella Valley primary care clinic with integrated services is used to demonstrate the much-needed approach of care to address health disparities that face low-income immigrants, migrant workers, and others without access to specialized care centers and providers. It is argued that mental health care should be part of all holistic treatment provided by primary care and family nurse practitioners. This has implications for curricula and practice development.

Factors influencing cardiometabolic monitoring practices in an adult community mental health service

People with serious mental illness are reported to live up to 25 years less than the general population. Cardiovascular disease and diabetes risk factors, as well as mental health, treatment, lifestyle, service provision, and socioeconomic factors, all contribute to this health inequity. Cardiometabolic monitoring (CMM) is one strategy used to attend to some cardiometabolic risk factors. The present study aimed to explore factors that influence decisions to undertake CMM in an Australian adult community mental health service. A CMM audit tool was designed to capture demographic, clinical, and care-provision factors. A 6-month retrospective file audit from the total population of consumers of an adult community mental health service was undertaken, where no existing CMM guidelines or practices were in place. The study findings confirmed a higher prevalence of cardiometabolic disorders in the study population compared to the general population. Complete CMM occurred in 24% of the study population (n = 94). No consumer demographic, socioeconomic, or clinical characteristics, or care-provision factors, were found to be predictors of complete CMM. The random manner in which CMM was observed to occur in the study highlights the need for standardized CMM guidelines and capacity-building strategies to improve current CMM practices.

Utilization of a cardiometabolic health nurse - a novel strategy to manage comorbid physical and mental illness

BACKGROUND

Comorbid chronic illnesses, such as cardiovascular disease, respiratory conditions, and type 2 diabetes are common among people with serious mental illness. Management of comorbid illness in the mental health setting is sometimes ad hoc and poorly delivered. Use of a cardiometabolic health nurse (CHN) is proposed as one strategy to improve the delivery of physical health care to this vulnerable population.

OBJECTIVE

To report the CHN's utilization of primary care and allied health referrals from a trial carried out in a regional community mental health service.

DESIGN

Feasibility study. Mental health consumers were referred by their case manager or mental health nurse to the CHN. The CHN coordinated the physical health care of community-based mental health consumers by identifying the need for, and providing referrals to, additional services, including primary care, allied health, and community-based services.

RESULTS

Sixty-two percent of participants referred to the CHN received referrals for primary care, allied health, and community-based services. Almost all referrals received follow-up by the CHN. Referrals were most commonly directed to a general practitioner and for nurse-delivered services.

CONCLUSION

The CHN role shows promise in coordinating the physical health of community-based mental health consumers. More studies on role integration and development of specific outcome measurement tools are needed. Journal of Comorbidity 2014;4:22-28.