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Physical health care for people with mental illness: Training needs for nurses
Nurse Education Today 33 (2013) 396–401
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Physical health care for people with mental illness: Training needs for nurses Brenda Happell a, b, c, d,⁎, Chris Platania-Phung b, c, d, David Scott a, b, c, d a
Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia Institute for Health and Social Science Research, Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia c Centre for Mental Health Nursing Innovation, Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia d School of Nursing and Midwifery, Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia b
a r t i c l e
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Article history: Accepted 18 January 2013 Keywords: Mental health Nurses Nursing role Physical health Survey design Training
s u m m a r y Aim: People diagnosed with serious mental illness have higher rates of physical morbidity and decreased longevity, yet these people are not adequately served by health care systems. Nurses may provide improved physical health support to consumers with serious mental illness but this is partly dependent on nurses having necessary skills and interest in training opportunities for this component of their work. This survey investigated Australian nurses' interest in training across areas of physical health care including lifestyle factors, cardiovascular disease, and identifying health risks. Methods: A nation-wide online survey of nurse members of the Australian College of Mental Health Nurses. The survey included an adapted version of a sub-section of the Physical Health Attitudes Scale. Participants were asked to indicate their interest in various aspects of physical health care training. Results: Most (91.6%) participants viewed educating nurses in physical health care as of moderate or significant value in improving the physical health of people with serious mental illness. Interest in training in all areas of physical health care was over 60% across the health care settings investigated (e.g. public, private, primary care). Forty-two percent sought training in all nine areas of physical health care, from supporting people with diabetes, to assisting consumers with sexually-related and lifestyle issues. Conclusions: The findings suggest that nurses in mental health services in Australia acknowledge the importance of training to improve physical health care of consumers with serious mental illness. Training programs and learning opportunities for nurses are necessary to reduce inequalities in health of people with serious mental illness. © 2013 Published by Elsevier Ltd.
Introduction In the last ten years there has been increasing recognition of significantly poorer health outcomes for people with serious mental illness (SMI). Studies comparing SMI groups to non-SMI identify a higher level of physical health problems (Filik et al., 2006; Carney et al., 2006). The risk of cardiovascular disease increases with second generation anti-psychotic medication use (Cowling, 2011), and lifestyle factors such as sedentariness, poor nutrition and smoking (Lawrence et al., 2009; Robson and Gray, 2007). Health services are not meeting the physical health needs of consumers with SMI (Viron and Stern, 2010; De Hert et al., 2011; Mitchell and Lord, 2010). Strategies are needed to increase physical health care standards. Nurses are the professional group in mental health services (Australian Institute of Health and Welfare, 2011) and can assist consumers to address associated risk factors (Brunero and Lamont, 2009;
⁎ Corresponding author at: Institute for Health and Social Science Research, Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia. Tel.: +61 7 49232164; fax: +61 7 49306402. E-mail addresses: [email protected] (B. Happell), [email protected] (C. Platania-Phung), [email protected] (D. Scott). 0260-6917/$ – see front matter © 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.nedt.2013.01.015
Muir-Cochrane, 2006; Park et al., 2011) and providing better access to physical health care (Bradshaw and Pedley, 2012; Muir-Cochrane, 2006; Robson and Gray, 2007; Blythe and White, 2012). More recently nurses have been involved in strategies to promote improved physical health care including: screening (Druss et al., 2010; Jordan et al., 2002; White et al., 2009), referrals and linking services (Smith et al., 2007), and advice on diet (Brown et al., 2011), physical activity (Ohlsen et al., 2005; Park et al., 2011), and smoking (Griffiths et al., 2010). Training nurses is identified as a strategy to address physical health care needs. However, it will only be of value if nurses want this training. Few studies have looked directly at the issue of training (Nash, 2005; Robson and Haddad, 2012; Howard and Gamble, 2011). Nash (2005) surveyed London-based nurses about training on physical health, including willingness to undertake training. Endorsement for training was very high (96%). Similarly Howard and Gamble (2011) in the UK found nurses viewed physical health care as relevant, and identified a need for training in diabetes care. Participants also indicated lack of confidence in providing physical health care services and 75% reported having no physical training during their time with the care provider. Robson and Haddad (2012) created a questionnaire, the Physical Health Attitude Scale, on nurse views on
B. Happell et al. / Nurse Education Today 33 (2013) 396–401
their physical health role, including items on whether nurses sought training in physical health care skills. Robson et al. (2012) briefly reported that in their sample of 585 mental health nurses, over 80% indicated interest in training on the topics of managing cardiovascular health, diabetes care and healthy eating, and 67% on how to discuss reproductive health. Reviews of physical health care training in mental health are also rare. Hardy et al. (2011) reviewed availability of evaluations of training and its efficacy for physical health care of consumers with SMI in mental health services. No studies were found of sufficient quality to inform issues of training and education of health professionals. There has been very little attention to the role of nurses in Australia, and education support for them (Happell et al., 2011). This is despite recommendations in policy, such as the Victoria Ministerial Advisory Committee on Mental Health (2011, Appendix 1, p.2), that the community mental health sector: “Provide the specialist mental health service system with training in the area of physical health, including physical assessments, healthy lifestyle counselling, nutritional and exercise advice and how to deliver health promotion education and advice.” Despite these goals, nurses working in mental health services in Australia have never been surveyed for their attitudes towards training for physical health care. The current paper reports on a national survey study of nurses in mental health care in Australia. The objective of the study was to identify nurses' views on a range of issues connected to physical health of consumers and how health care could be improved through nurse-based and general approaches. Nurse interest in training in physical health care was major issues investigated. Specifically, the objective was to determine the level of nurse interest in training in physical health (e.g. cardiovascular health management, identifying risks to physical health), and perception of efficacy of nurse training to improve physical health of consumers with SMI in general. The key questions were: • To what extent do nurses see education and training of nurses (e.g. in the workplace) as an avenue for improving physical health of consumers with SMI? • Do nurses in mental health services want training in physical health care? If so, in what areas? • Are nurses' attitudes to training influenced by demographic characteristics (e.g. gender, years as registered nurse)? If so, in what areas of training? Method Design This cross-sectional study involved an email survey of members of the national organisation for nurses in mental health services, the Australian College of Mental Health Nursing (ACMHN). The ACMHN holds the largest database of nurses working in this field and is therefore the most effective way to provide access. Measures The survey was composed of several sections on a range of physical health care issues. The current paper focuses on questions directly related to nurse education and training in physical health care, and to the demographic characteristics of participants.
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“Workplace training of nurses on physical care tasks and responsibilities” was one of the eight strategies included. The response options were: Negative value/Counter-productive, No value, Little value, Moderate value, Significant value. Physical Health Attitude Scale The questions about nurses' attitudes for training were drawn from Robson and Haddad's (2012) Physical Health Attitude Scale (PHASe) (with the permission of the authors). This instrument was developed to investigate attitudes of UK nurses to consumers with SMI and the nurse role in physical health care. Adopting the subsection of PHASe on training, participants were asked to respond to a series of questions by completing the phrase: “I would like more training on:” Training topics were described as tasks, e.g. “How to help clients stop smoking”. The response options were Yes, Not sure, and No. Some adjustments were made to Robson and Haddad's (2012) original questions. “Client” was changed to “consumer” — the commonly used term in Australia to describe people with SMI in contact with mental health services. Given the significant issue of screening and physical assessment gaps in mental health care services, an item was added: “How to identify consumers ‘at risk’ of physical illnesses”. Also, a statement was included on general communication around sensitive topics (“How to discuss sensitive health risks with consumers (e.g. sexual health, illicit drug use)”). Nurse Background Participants were asked to report sex, duration as a registered nurse and of employment in mental health care, and whether credentialed by the ACMHN. Credentialing was implemented by the ACMHN as a means to recognise expertise, qualifications and professional development in mental health nursing. Nurses are eligible to apply for a credential if they have a specialist qualification in mental health nursing and provide evidence of involvement in professional development activities (Australian College of Mental Health Nurses, 2012). Survey Development The survey primarily consisted of new questions that addressed a range of issues related to physical health care of consumers with SMI in an Australian context, and was informed by the literature as well as local research conducted by the research team. A pilot was conducted with 19 public health academic and practice staff (mainly nurses). They were asked to complete the survey and provide feedback on its comprehensibility and ease of use. The survey was reported to be straightforward with only minor amendments required (such as adjusting the response format for some questions). Ethics The study was approved by the university ethics committee. The invitation email included an attached document on arrangements to ensure confidentiality and indicating participation was voluntary. Invitees were informed that the researchers and the ACMHN did not have information on who did or did not participate, and that data would only be accessed by the research team. Procedure
Strategies for Improving Physical Health of Consumers with Serious Mental Illness A list of general approaches to physical health care improvements of consumers was included. Participants were asked to rate “their potential for contributing to improving the physical health of consumers”.
The central office of the ACMHN sent the invitation to their members on behalf of the research team. The current recruitment approach did not allow for strategic sampling; sampling was non-random. The survey was ‘open’ to the membership body between May and July of 2012. Each invitation included a direct link to the survey. Participants could
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not proceed to the next section of the survey without responding to the forced-choice questions. In order to ensure as large a sample as possible email reminders were used (Priest et al., 2008), several reminder emails were sent, and all reminders led to increases in the response rate. The final response rate was 22% (based on responses divided by an estimated membership size of 2,900). Data Analysis Data analysis was conducted in SPSS 19 (SPSS Inc., 2010, Chicago, IL). The percentage of responses was inspected for the overall sample and for sub-groups (e.g. public inpatient nurses). On the question of need for training there was a small proportion who responded ‘not sure’ for each of the areas of training (range from 5% to 10.3%). In order to examine associations between interest in training and nurse background, the ‘not sure’ and ‘no’ groups were merged to create a dichotomous variable on interest in training for each area of training (‘yes’ versus ‘no/not sure’). Point-biserial and Spearman rho were correlations calculated on nurse background and interest in training.
NSW (n=175), followed by Queensland (n=163), Victoria (n= 154) and South Australia (n=48). Sixty two and a half percent of participants had been a registered nurse between 21 and 40 years. The range of time as a registered nurse ranged from 1 to 48 years. Sixty one percent had worked in mental health care for between 11 and 30 years. The range of time in mental health care was less than one year to 50 years. Forty two point one percent had (or previously had) a mental health nurse credential with the ACMHN.
Nurse Views on Nurse Workplace Training as a Strategy for Improving Outcomes for Consumers with SMI Fig. 1 presents the responses of nurses to the question on nurse workplace training on tasks and responsibilities. This question is concerned with the responses were ‘negative value/counter-productive’ 1% (n= 6), ‘no value’ 1% (n=7), ‘little value'6% (n=41), ‘moderate value’ 26% (n=170), and ‘significant value’ 65% (n=41).
Findings
Nurse Interest in Training on Physical Health Care
Nurse Background
Table 2 presents the raw responses to the section on interest in training. The distribution of ‘yes’, ‘not sure’ and ‘no’ responses was similar for all areas — the most common response was ‘yes’, followed by ‘no’ and ‘not sure’. Over 60% expressed an interest in each of all nine training areas listed. Over 70% indicated interesting in training for: ‘How to care for MH consumers with diabetes’ and ‘How to help MH consumers manage their cardiovascular health’. The training areas with the lowest ‘yes’ response were for reproductive health and sensitive health risks (sexual health, illicit drug use), and smoking cessation. Given that responses were similar across the areas of training it was inferred that there may be overarching groups that had common responses in all areas. It was found that 42% responded ‘yes’ to all areas, and 9% ‘no’ to all areas. As the largest group of participants were employed in public mental health services (consistent with the general population of nurses in mental health care in Australia), each sub-group was examined to see if this general pattern of responses was consistent across the groups. For nurses in inpatient services only, over 70% wanted training in each of all the areas except smoking and healthy eating. It was found that the pattern of responses was similar across for all nurse groups (Table 1).
Table 1 shows the demographics for nurse participants. Seventy two point seven percent were female. The largest represented state was
Table 1 Participant characteristics. Background
Overall N= 643 n
%
Gender Male Female Missing
175 468 1
27.2% 72.7% 0.2%
State/territory of residence Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
11 175 12 163 48 17 154 63
1.7% 27.2% 1.9% 25.3% 7.5% 2.6% 23.9% 9.8%
Nurse group Public inpatient Public community Public inpatient & community Public: not inpatient, nor community Other
110 230 17 97 189
17.1% 35.8% 2.6% 15.1% 29.4%
Duration as registered nurse 0–10 years 11–20 years 21–30 years 31–40 years Over 40 years
101 112 209 193 26
15.7% 17.4% 32.5% 30.0% 4.0%
Duration in mental health care 0–10 years 11–20 years 21–30 years 31–40 years Over 40 years
148 187 206 87 15
23.0% 29.1% 32.0% 13.5% 2.3%
ACMHN credentials Has credentials No credentials
271 372
42.1% 57.8%
Fig. 1. Response to nurse physical health training as a strategy for improving physical health of consumers with serious mental illness (n = 643).
B. Happell et al. / Nurse Education Today 33 (2013) 396–401 Table 2 Distribution of responses to the nurse training section. I would like more training on….
Yes n (%)
Not sure n (%)
No n (%)
1: How to care for MH consumers with diabetes
459 (71.4%) 490 (76.2%) 413 (64.2%) 427 (66.4%) 405 (63.0%) 441 (68.6%) 401 (62.4%) 445 (69.2%) 399 (62.1%)
33 (5.1%) 40 (6.2%) 60 (9.3%) 57 (8.9%) 54 (8.4%) 54 (8.4%) 66 (10.3%) 44 (6.8%) 50 (7.8%)
151 (23.5%) 113 (17.6%) 170 (26.4%) 159 (24.7%) 184 (28.6%) 148 (23.0%) 176 (27.4%) 154 (24.0%) 194 (30.2%)
2: How to help MH consumers manage their cardiovascular health 3: Interventions to help consumers eat more healthily 4: How to help consumers exercise safely and effectively 5: How to help consumers stop smoking 6: Interventions to help consumers manage their weight 7: How to discuss reproductive health issues with consumers 8: How to identify consumers ‘at risk’ of physical illnesses 9: How to discuss sensitive health risks with consumers (e.g. sexual health, illicit drug use)
Nurse Differences in Interest in Physical Health Care Training Table 3 displays correlations between desire for training in each physical health care and nurse background variable (gender, years in mental health care and as a registered nurse, and whether or not the participant had an accreditation with the ACMHN). There was no association between gender and interest in training. Years in mental health care was associated with slightly less interest in training in all areas except diabetes and exercise. Years as a registered nurse was slightly associated with less interest in training in most areas of physical health care — namely CVD, smoking, weight, reproductive, risk identification, sensitive risks, CVD and eating. There were small, statistically significant correlations between ACMHN credentials and interest in training for cardiovascular health, healthy eating and sensitive health risks. In all cases, those without a ACMHN credentials were more likely to respond ‘yes’ to training, relative to those with ACMHN credentials. Discussion The results of this national survey suggest that nurses employed in mental health care identify education and training in physical health care as a valuable way to improve health outcomes for consumers with SMI, 65% indicating this would be of “significant value”. In addition, the participants, who worked in a wide variety of mental health care settings in Australia, were generally interested in further training in physical health care. This is the first national data available on
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nurse interest in advancing physical health care knowledge and skills from a mental health context. The findings are consistent with studies in the UK (Howard and Gamble, 2011; Nash, 2011). In particular, the current study adopted the questions on training developed by Robson et al. (2012), allowing some direct and general comparison to take place. Similar to Robson et al. (2012), the highest interest in training need was for cardiovascular health management, and diabetes, over 80% in the UK sample (Robson et al., 2012), and 76% in the current study 76% (cardiovascular) and 71% (diabetes). Additionally, responses were similar for: smoking (UK 69%; 63% Australia), and reproductive health (UK 67%; 62% Australia). In the current study, the lowest proportion was for sensitive health risks, such as “sexual health” (62%); this item was not part of the UK study. The lower ranking of identified need for training for the areas of smoking and sexual issues and can be interpreted in relation to previous literature on these areas. Smoking is a complex issue for nurses (Mc Cloughen, 2003) particularly conflicts between health promotion (reduce risk of lung cancer and other physical disorders) and activities that are perceived to build a therapeutic relationship (smoking with client or as way to reward client for progress). Less interest in training about smoking cessation may reflect nurses not viewing it as a good means of supporting consumers in recovery, while other nurses may feel they are already competent in this area. Still it is important to note that nurses still indicated a need for training around smoking cessation and sex-related issues, both at over 60%. It has been found that nurses in mental health services do not feel comfortable in discussing sexual-related issues with consumers (Quinn et al., 2011). Sexual side effects have been identified as a major reason for consumers ceasing or significantly reducing their medication intake (Quinn et al., 2011) suggesting that even aside from human rights issues, nurses need to actively address sexual issues to enhance the physical and mental health of consumers. Research suggests that a brief training intervention can lead to sustained and positive practice change for nurses in responding to the sexual concerns of consumers (Quinn and Happell, 2012). It is therefore important that this area be addressed as a matter of priority. The nursing profession is underpinned by the concept of holism (Quinn and Happell, 2012; Cowling, 2011). A higher level of skill in providing physical health care has been argued in favour of the current Australian model of comprehensive nursing education (Povlsen and Borup, 2011). However, this argument is not supported by the decreasing life expectancy for people with SMI (Gray, 2012). The findings of the current study demonstrate nurses' identified need for further training, suggesting that comprehensive education does not adequately skill nurses for physical health care (Povlsen and Borup, 2011) or at least that ongoing training is required to remain current. The fact that most nurses in the current sample identify this need is encouraging. If nurses are to realise their potential to
Table 3 Associations between nurse background and interest in training.
1: 2: 3: 4: 5: 6: 7: 8: 9:
How to care for MH consumers with diabetes How to help MH consumers manage their cardiovascular health Interventions to help consumers eat more healthily How to help consumers exercise safely and effectively How to help consumers stop smoking Interventions to help consumers manage their weight How to discuss reproductive health issues with consumers How to identify consumers ‘at risk’ of physical illnesses How to discuss sensitive health risks with consumers (e.g. sexual health, illicit drug use)
Gender
Years: mental health carea
Years: registered nursea
ACMHN credential
−.05 .01 −.05 −.04 −.03 −.01 −.04 .02 .00
.03 .10* .11* .05 .10* .10* .14* .11* .12**
.05 .05 .12** .08* .10* .09* .13** .07 .11**
−.07 −.08* −.08* −.07 −.02 −.05 −.02 −.07 −.11**
a Point-biserial correlations. All other correlations are Spearman's rho. Interest in training based on binary variable (‘yes’ versus ‘no/not sure’), all other variables based on raw distributions.
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provide physical health care (Blythe and White, 2012; Bradshaw and Pedley, 2012; Happell et al., 2012) training needs must become a high priority. If training is identified as important, a strategic approach is needed. A good starting point may be to investigate training programs that are already available and accessible. For instance, in Australia, courses have been developed that would be highly relevant in skilling nurses for physical health issues for people diagnosed with serious mental illness. As one example, the National Diabetes Services Scheme provides a “Diabetes Online Learning Program for Mental Health Workers” (see http://www.otaus.com.au/pdeducationcontentpages/on-line-programs/ introduction-to-diabetes-for-mental-health-workers), that includes case study learning. The provision of training on-line may assist in overcoming some of the identified barriers created by high workloads and geographical distances (Happell et al., 2012). Limitations There are limitations to the study that require caution in interpreting the findings of this research. The response rate for this survey was 22% and it is possible that the nurses who responded are more concerned about physical health of consumers and have a stronger interest in physical health care. This may have created an overestimate of interest in physical health care training. This possible bias in the sample may also have been tempered by the nurses feeling they already had the skills and knowledge to undertake physical health care, or were already accessing training. Despite the limitations however, the findings suggest a high proportion of nurses in Australia that want training in this area, an encouraging sign in the quest for improved physical health care for people with SMI. Conclusion Nurses need current knowledge and skill in physical health care if they are to contribute to improving the physical health of people with SMI. Training is an important component in ensuring that level of knowledge and skill is available. The nurse participants in this research identified the need for training in a broad range of areas. To address a serious health inequality and meet the goal of developing robust, flexible and comprehensive health care in Australia, a strategic approach to developing, implementing and evaluating training in these areas must be prioritised. Funding Research Advancement Award Scheme and Merit Grant Scheme of Central Queensland University provided the funding to make this work possible. Acknowledgements The authors would like to thank the mental health nurses for their time and valuable input. Our thanks to the Australian College of Mental Health Nurses, particularly Kim Ryan and Haylie Maylia for their invaluable assistance in distributing the survey. References Australian College of Mental Health Nurses, 2012. Credentialling for Practice Program. [Online] Australian College of Mental Health Nurses, Canberra Available: http:// acmhn.org/credentialing/what-is-credentialing.html [Accessed 12 August 2012]. Australian Institute of Health and Welfare, 2011. Nursing and Midwifery Labour Force 2009. Australian Institute of Health and Welfare, Canberra. Blythe, J., White, J., 2012. Role of the mental health nurse towards physical health care in serious mental illness: an integrative review of 10 years of UK literature. International Journal of Mental Health Nursing 21, 193–201.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Physical health care for people with mental illness: Training needs for nurses Brenda Happell a, b, c, d,⁎, Chris Platania-Phung b, c, d, David Scott a, b, c, d a
Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia Institute for Health and Social Science Research, Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia c Centre for Mental Health Nursing Innovation, Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia d School of Nursing and Midwifery, Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia b
a r t i c l e
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Article history: Accepted 18 January 2013 Keywords: Mental health Nurses Nursing role Physical health Survey design Training
s u m m a r y Aim: People diagnosed with serious mental illness have higher rates of physical morbidity and decreased longevity, yet these people are not adequately served by health care systems. Nurses may provide improved physical health support to consumers with serious mental illness but this is partly dependent on nurses having necessary skills and interest in training opportunities for this component of their work. This survey investigated Australian nurses' interest in training across areas of physical health care including lifestyle factors, cardiovascular disease, and identifying health risks. Methods: A nation-wide online survey of nurse members of the Australian College of Mental Health Nurses. The survey included an adapted version of a sub-section of the Physical Health Attitudes Scale. Participants were asked to indicate their interest in various aspects of physical health care training. Results: Most (91.6%) participants viewed educating nurses in physical health care as of moderate or significant value in improving the physical health of people with serious mental illness. Interest in training in all areas of physical health care was over 60% across the health care settings investigated (e.g. public, private, primary care). Forty-two percent sought training in all nine areas of physical health care, from supporting people with diabetes, to assisting consumers with sexually-related and lifestyle issues. Conclusions: The findings suggest that nurses in mental health services in Australia acknowledge the importance of training to improve physical health care of consumers with serious mental illness. Training programs and learning opportunities for nurses are necessary to reduce inequalities in health of people with serious mental illness. © 2013 Published by Elsevier Ltd.
Introduction In the last ten years there has been increasing recognition of significantly poorer health outcomes for people with serious mental illness (SMI). Studies comparing SMI groups to non-SMI identify a higher level of physical health problems (Filik et al., 2006; Carney et al., 2006). The risk of cardiovascular disease increases with second generation anti-psychotic medication use (Cowling, 2011), and lifestyle factors such as sedentariness, poor nutrition and smoking (Lawrence et al., 2009; Robson and Gray, 2007). Health services are not meeting the physical health needs of consumers with SMI (Viron and Stern, 2010; De Hert et al., 2011; Mitchell and Lord, 2010). Strategies are needed to increase physical health care standards. Nurses are the professional group in mental health services (Australian Institute of Health and Welfare, 2011) and can assist consumers to address associated risk factors (Brunero and Lamont, 2009;
⁎ Corresponding author at: Institute for Health and Social Science Research, Central Queensland University, Bruce Hwy, Rockhampton, Queensland, 4702, Australia. Tel.: +61 7 49232164; fax: +61 7 49306402. E-mail addresses: [email protected] (B. Happell), [email protected] (C. Platania-Phung), [email protected] (D. Scott). 0260-6917/$ – see front matter © 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.nedt.2013.01.015
Muir-Cochrane, 2006; Park et al., 2011) and providing better access to physical health care (Bradshaw and Pedley, 2012; Muir-Cochrane, 2006; Robson and Gray, 2007; Blythe and White, 2012). More recently nurses have been involved in strategies to promote improved physical health care including: screening (Druss et al., 2010; Jordan et al., 2002; White et al., 2009), referrals and linking services (Smith et al., 2007), and advice on diet (Brown et al., 2011), physical activity (Ohlsen et al., 2005; Park et al., 2011), and smoking (Griffiths et al., 2010). Training nurses is identified as a strategy to address physical health care needs. However, it will only be of value if nurses want this training. Few studies have looked directly at the issue of training (Nash, 2005; Robson and Haddad, 2012; Howard and Gamble, 2011). Nash (2005) surveyed London-based nurses about training on physical health, including willingness to undertake training. Endorsement for training was very high (96%). Similarly Howard and Gamble (2011) in the UK found nurses viewed physical health care as relevant, and identified a need for training in diabetes care. Participants also indicated lack of confidence in providing physical health care services and 75% reported having no physical training during their time with the care provider. Robson and Haddad (2012) created a questionnaire, the Physical Health Attitude Scale, on nurse views on
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their physical health role, including items on whether nurses sought training in physical health care skills. Robson et al. (2012) briefly reported that in their sample of 585 mental health nurses, over 80% indicated interest in training on the topics of managing cardiovascular health, diabetes care and healthy eating, and 67% on how to discuss reproductive health. Reviews of physical health care training in mental health are also rare. Hardy et al. (2011) reviewed availability of evaluations of training and its efficacy for physical health care of consumers with SMI in mental health services. No studies were found of sufficient quality to inform issues of training and education of health professionals. There has been very little attention to the role of nurses in Australia, and education support for them (Happell et al., 2011). This is despite recommendations in policy, such as the Victoria Ministerial Advisory Committee on Mental Health (2011, Appendix 1, p.2), that the community mental health sector: “Provide the specialist mental health service system with training in the area of physical health, including physical assessments, healthy lifestyle counselling, nutritional and exercise advice and how to deliver health promotion education and advice.” Despite these goals, nurses working in mental health services in Australia have never been surveyed for their attitudes towards training for physical health care. The current paper reports on a national survey study of nurses in mental health care in Australia. The objective of the study was to identify nurses' views on a range of issues connected to physical health of consumers and how health care could be improved through nurse-based and general approaches. Nurse interest in training in physical health care was major issues investigated. Specifically, the objective was to determine the level of nurse interest in training in physical health (e.g. cardiovascular health management, identifying risks to physical health), and perception of efficacy of nurse training to improve physical health of consumers with SMI in general. The key questions were: • To what extent do nurses see education and training of nurses (e.g. in the workplace) as an avenue for improving physical health of consumers with SMI? • Do nurses in mental health services want training in physical health care? If so, in what areas? • Are nurses' attitudes to training influenced by demographic characteristics (e.g. gender, years as registered nurse)? If so, in what areas of training? Method Design This cross-sectional study involved an email survey of members of the national organisation for nurses in mental health services, the Australian College of Mental Health Nursing (ACMHN). The ACMHN holds the largest database of nurses working in this field and is therefore the most effective way to provide access. Measures The survey was composed of several sections on a range of physical health care issues. The current paper focuses on questions directly related to nurse education and training in physical health care, and to the demographic characteristics of participants.
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“Workplace training of nurses on physical care tasks and responsibilities” was one of the eight strategies included. The response options were: Negative value/Counter-productive, No value, Little value, Moderate value, Significant value. Physical Health Attitude Scale The questions about nurses' attitudes for training were drawn from Robson and Haddad's (2012) Physical Health Attitude Scale (PHASe) (with the permission of the authors). This instrument was developed to investigate attitudes of UK nurses to consumers with SMI and the nurse role in physical health care. Adopting the subsection of PHASe on training, participants were asked to respond to a series of questions by completing the phrase: “I would like more training on:” Training topics were described as tasks, e.g. “How to help clients stop smoking”. The response options were Yes, Not sure, and No. Some adjustments were made to Robson and Haddad's (2012) original questions. “Client” was changed to “consumer” — the commonly used term in Australia to describe people with SMI in contact with mental health services. Given the significant issue of screening and physical assessment gaps in mental health care services, an item was added: “How to identify consumers ‘at risk’ of physical illnesses”. Also, a statement was included on general communication around sensitive topics (“How to discuss sensitive health risks with consumers (e.g. sexual health, illicit drug use)”). Nurse Background Participants were asked to report sex, duration as a registered nurse and of employment in mental health care, and whether credentialed by the ACMHN. Credentialing was implemented by the ACMHN as a means to recognise expertise, qualifications and professional development in mental health nursing. Nurses are eligible to apply for a credential if they have a specialist qualification in mental health nursing and provide evidence of involvement in professional development activities (Australian College of Mental Health Nurses, 2012). Survey Development The survey primarily consisted of new questions that addressed a range of issues related to physical health care of consumers with SMI in an Australian context, and was informed by the literature as well as local research conducted by the research team. A pilot was conducted with 19 public health academic and practice staff (mainly nurses). They were asked to complete the survey and provide feedback on its comprehensibility and ease of use. The survey was reported to be straightforward with only minor amendments required (such as adjusting the response format for some questions). Ethics The study was approved by the university ethics committee. The invitation email included an attached document on arrangements to ensure confidentiality and indicating participation was voluntary. Invitees were informed that the researchers and the ACMHN did not have information on who did or did not participate, and that data would only be accessed by the research team. Procedure
Strategies for Improving Physical Health of Consumers with Serious Mental Illness A list of general approaches to physical health care improvements of consumers was included. Participants were asked to rate “their potential for contributing to improving the physical health of consumers”.
The central office of the ACMHN sent the invitation to their members on behalf of the research team. The current recruitment approach did not allow for strategic sampling; sampling was non-random. The survey was ‘open’ to the membership body between May and July of 2012. Each invitation included a direct link to the survey. Participants could
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not proceed to the next section of the survey without responding to the forced-choice questions. In order to ensure as large a sample as possible email reminders were used (Priest et al., 2008), several reminder emails were sent, and all reminders led to increases in the response rate. The final response rate was 22% (based on responses divided by an estimated membership size of 2,900). Data Analysis Data analysis was conducted in SPSS 19 (SPSS Inc., 2010, Chicago, IL). The percentage of responses was inspected for the overall sample and for sub-groups (e.g. public inpatient nurses). On the question of need for training there was a small proportion who responded ‘not sure’ for each of the areas of training (range from 5% to 10.3%). In order to examine associations between interest in training and nurse background, the ‘not sure’ and ‘no’ groups were merged to create a dichotomous variable on interest in training for each area of training (‘yes’ versus ‘no/not sure’). Point-biserial and Spearman rho were correlations calculated on nurse background and interest in training.
NSW (n=175), followed by Queensland (n=163), Victoria (n= 154) and South Australia (n=48). Sixty two and a half percent of participants had been a registered nurse between 21 and 40 years. The range of time as a registered nurse ranged from 1 to 48 years. Sixty one percent had worked in mental health care for between 11 and 30 years. The range of time in mental health care was less than one year to 50 years. Forty two point one percent had (or previously had) a mental health nurse credential with the ACMHN.
Nurse Views on Nurse Workplace Training as a Strategy for Improving Outcomes for Consumers with SMI Fig. 1 presents the responses of nurses to the question on nurse workplace training on tasks and responsibilities. This question is concerned with the responses were ‘negative value/counter-productive’ 1% (n= 6), ‘no value’ 1% (n=7), ‘little value'6% (n=41), ‘moderate value’ 26% (n=170), and ‘significant value’ 65% (n=41).
Findings
Nurse Interest in Training on Physical Health Care
Nurse Background
Table 2 presents the raw responses to the section on interest in training. The distribution of ‘yes’, ‘not sure’ and ‘no’ responses was similar for all areas — the most common response was ‘yes’, followed by ‘no’ and ‘not sure’. Over 60% expressed an interest in each of all nine training areas listed. Over 70% indicated interesting in training for: ‘How to care for MH consumers with diabetes’ and ‘How to help MH consumers manage their cardiovascular health’. The training areas with the lowest ‘yes’ response were for reproductive health and sensitive health risks (sexual health, illicit drug use), and smoking cessation. Given that responses were similar across the areas of training it was inferred that there may be overarching groups that had common responses in all areas. It was found that 42% responded ‘yes’ to all areas, and 9% ‘no’ to all areas. As the largest group of participants were employed in public mental health services (consistent with the general population of nurses in mental health care in Australia), each sub-group was examined to see if this general pattern of responses was consistent across the groups. For nurses in inpatient services only, over 70% wanted training in each of all the areas except smoking and healthy eating. It was found that the pattern of responses was similar across for all nurse groups (Table 1).
Table 1 shows the demographics for nurse participants. Seventy two point seven percent were female. The largest represented state was
Table 1 Participant characteristics. Background
Overall N= 643 n
%
Gender Male Female Missing
175 468 1
27.2% 72.7% 0.2%
State/territory of residence Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
11 175 12 163 48 17 154 63
1.7% 27.2% 1.9% 25.3% 7.5% 2.6% 23.9% 9.8%
Nurse group Public inpatient Public community Public inpatient & community Public: not inpatient, nor community Other
110 230 17 97 189
17.1% 35.8% 2.6% 15.1% 29.4%
Duration as registered nurse 0–10 years 11–20 years 21–30 years 31–40 years Over 40 years
101 112 209 193 26
15.7% 17.4% 32.5% 30.0% 4.0%
Duration in mental health care 0–10 years 11–20 years 21–30 years 31–40 years Over 40 years
148 187 206 87 15
23.0% 29.1% 32.0% 13.5% 2.3%
ACMHN credentials Has credentials No credentials
271 372
42.1% 57.8%
Fig. 1. Response to nurse physical health training as a strategy for improving physical health of consumers with serious mental illness (n = 643).
B. Happell et al. / Nurse Education Today 33 (2013) 396–401 Table 2 Distribution of responses to the nurse training section. I would like more training on….
Yes n (%)
Not sure n (%)
No n (%)
1: How to care for MH consumers with diabetes
459 (71.4%) 490 (76.2%) 413 (64.2%) 427 (66.4%) 405 (63.0%) 441 (68.6%) 401 (62.4%) 445 (69.2%) 399 (62.1%)
33 (5.1%) 40 (6.2%) 60 (9.3%) 57 (8.9%) 54 (8.4%) 54 (8.4%) 66 (10.3%) 44 (6.8%) 50 (7.8%)
151 (23.5%) 113 (17.6%) 170 (26.4%) 159 (24.7%) 184 (28.6%) 148 (23.0%) 176 (27.4%) 154 (24.0%) 194 (30.2%)
2: How to help MH consumers manage their cardiovascular health 3: Interventions to help consumers eat more healthily 4: How to help consumers exercise safely and effectively 5: How to help consumers stop smoking 6: Interventions to help consumers manage their weight 7: How to discuss reproductive health issues with consumers 8: How to identify consumers ‘at risk’ of physical illnesses 9: How to discuss sensitive health risks with consumers (e.g. sexual health, illicit drug use)
Nurse Differences in Interest in Physical Health Care Training Table 3 displays correlations between desire for training in each physical health care and nurse background variable (gender, years in mental health care and as a registered nurse, and whether or not the participant had an accreditation with the ACMHN). There was no association between gender and interest in training. Years in mental health care was associated with slightly less interest in training in all areas except diabetes and exercise. Years as a registered nurse was slightly associated with less interest in training in most areas of physical health care — namely CVD, smoking, weight, reproductive, risk identification, sensitive risks, CVD and eating. There were small, statistically significant correlations between ACMHN credentials and interest in training for cardiovascular health, healthy eating and sensitive health risks. In all cases, those without a ACMHN credentials were more likely to respond ‘yes’ to training, relative to those with ACMHN credentials. Discussion The results of this national survey suggest that nurses employed in mental health care identify education and training in physical health care as a valuable way to improve health outcomes for consumers with SMI, 65% indicating this would be of “significant value”. In addition, the participants, who worked in a wide variety of mental health care settings in Australia, were generally interested in further training in physical health care. This is the first national data available on
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nurse interest in advancing physical health care knowledge and skills from a mental health context. The findings are consistent with studies in the UK (Howard and Gamble, 2011; Nash, 2011). In particular, the current study adopted the questions on training developed by Robson et al. (2012), allowing some direct and general comparison to take place. Similar to Robson et al. (2012), the highest interest in training need was for cardiovascular health management, and diabetes, over 80% in the UK sample (Robson et al., 2012), and 76% in the current study 76% (cardiovascular) and 71% (diabetes). Additionally, responses were similar for: smoking (UK 69%; 63% Australia), and reproductive health (UK 67%; 62% Australia). In the current study, the lowest proportion was for sensitive health risks, such as “sexual health” (62%); this item was not part of the UK study. The lower ranking of identified need for training for the areas of smoking and sexual issues and can be interpreted in relation to previous literature on these areas. Smoking is a complex issue for nurses (Mc Cloughen, 2003) particularly conflicts between health promotion (reduce risk of lung cancer and other physical disorders) and activities that are perceived to build a therapeutic relationship (smoking with client or as way to reward client for progress). Less interest in training about smoking cessation may reflect nurses not viewing it as a good means of supporting consumers in recovery, while other nurses may feel they are already competent in this area. Still it is important to note that nurses still indicated a need for training around smoking cessation and sex-related issues, both at over 60%. It has been found that nurses in mental health services do not feel comfortable in discussing sexual-related issues with consumers (Quinn et al., 2011). Sexual side effects have been identified as a major reason for consumers ceasing or significantly reducing their medication intake (Quinn et al., 2011) suggesting that even aside from human rights issues, nurses need to actively address sexual issues to enhance the physical and mental health of consumers. Research suggests that a brief training intervention can lead to sustained and positive practice change for nurses in responding to the sexual concerns of consumers (Quinn and Happell, 2012). It is therefore important that this area be addressed as a matter of priority. The nursing profession is underpinned by the concept of holism (Quinn and Happell, 2012; Cowling, 2011). A higher level of skill in providing physical health care has been argued in favour of the current Australian model of comprehensive nursing education (Povlsen and Borup, 2011). However, this argument is not supported by the decreasing life expectancy for people with SMI (Gray, 2012). The findings of the current study demonstrate nurses' identified need for further training, suggesting that comprehensive education does not adequately skill nurses for physical health care (Povlsen and Borup, 2011) or at least that ongoing training is required to remain current. The fact that most nurses in the current sample identify this need is encouraging. If nurses are to realise their potential to
Table 3 Associations between nurse background and interest in training.
1: 2: 3: 4: 5: 6: 7: 8: 9:
How to care for MH consumers with diabetes How to help MH consumers manage their cardiovascular health Interventions to help consumers eat more healthily How to help consumers exercise safely and effectively How to help consumers stop smoking Interventions to help consumers manage their weight How to discuss reproductive health issues with consumers How to identify consumers ‘at risk’ of physical illnesses How to discuss sensitive health risks with consumers (e.g. sexual health, illicit drug use)
Gender
Years: mental health carea
Years: registered nursea
ACMHN credential
−.05 .01 −.05 −.04 −.03 −.01 −.04 .02 .00
.03 .10* .11* .05 .10* .10* .14* .11* .12**
.05 .05 .12** .08* .10* .09* .13** .07 .11**
−.07 −.08* −.08* −.07 −.02 −.05 −.02 −.07 −.11**
a Point-biserial correlations. All other correlations are Spearman's rho. Interest in training based on binary variable (‘yes’ versus ‘no/not sure’), all other variables based on raw distributions.
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provide physical health care (Blythe and White, 2012; Bradshaw and Pedley, 2012; Happell et al., 2012) training needs must become a high priority. If training is identified as important, a strategic approach is needed. A good starting point may be to investigate training programs that are already available and accessible. For instance, in Australia, courses have been developed that would be highly relevant in skilling nurses for physical health issues for people diagnosed with serious mental illness. As one example, the National Diabetes Services Scheme provides a “Diabetes Online Learning Program for Mental Health Workers” (see http://www.otaus.com.au/pdeducationcontentpages/on-line-programs/ introduction-to-diabetes-for-mental-health-workers), that includes case study learning. The provision of training on-line may assist in overcoming some of the identified barriers created by high workloads and geographical distances (Happell et al., 2012). Limitations There are limitations to the study that require caution in interpreting the findings of this research. The response rate for this survey was 22% and it is possible that the nurses who responded are more concerned about physical health of consumers and have a stronger interest in physical health care. This may have created an overestimate of interest in physical health care training. This possible bias in the sample may also have been tempered by the nurses feeling they already had the skills and knowledge to undertake physical health care, or were already accessing training. Despite the limitations however, the findings suggest a high proportion of nurses in Australia that want training in this area, an encouraging sign in the quest for improved physical health care for people with SMI. Conclusion Nurses need current knowledge and skill in physical health care if they are to contribute to improving the physical health of people with SMI. Training is an important component in ensuring that level of knowledge and skill is available. The nurse participants in this research identified the need for training in a broad range of areas. To address a serious health inequality and meet the goal of developing robust, flexible and comprehensive health care in Australia, a strategic approach to developing, implementing and evaluating training in these areas must be prioritised. Funding Research Advancement Award Scheme and Merit Grant Scheme of Central Queensland University provided the funding to make this work possible. Acknowledgements The authors would like to thank the mental health nurses for their time and valuable input. Our thanks to the Australian College of Mental Health Nurses, particularly Kim Ryan and Haylie Maylia for their invaluable assistance in distributing the survey. References Australian College of Mental Health Nurses, 2012. Credentialling for Practice Program. [Online] Australian College of Mental Health Nurses, Canberra Available: http:// acmhn.org/credentialing/what-is-credentialing.html [Accessed 12 August 2012]. Australian Institute of Health and Welfare, 2011. Nursing and Midwifery Labour Force 2009. Australian Institute of Health and Welfare, Canberra. Blythe, J., White, J., 2012. Role of the mental health nurse towards physical health care in serious mental illness: an integrative review of 10 years of UK literature. International Journal of Mental Health Nursing 21, 193–201.
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