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Perspectives in Psychiatric Care
ISSN 0031-5990
Lessons Learned From the Trial of a Cardiometabolic Health Nurse Brenda Happell, PhD, Danya Hodgetts, PhD, Robert Stanton, BHMSC (Hons), Freyja Millar, RN, MNP, Chris Platania Phung, PhD, and David Scott, PhD Brenda Happell, PhD, is Professor of Mental Health Nursing, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Danya Hodgetts, PhD, is Adjunct Research Fellow, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Robert Stanton, BHMSc (Hons), is Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Freyja Millar, RN, MNP, is Mental Health Nurse, Eastern Health, Melbourne, Victoria, Australia; Chris Platania Phung, PhD, is Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; David Scott, PhD, is Adjunct Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia and is AIMSS Postdoctoral Research Fellow, NorthWest Academic Centre, University of Melbourne, Melbourne, Victoria, Australia.
Search terms: Physical health care, severe mental illness, mental health nursing, chronic illness Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no actual or potential conflicts of interest. First Received July 27, 2014; Final Revision received September 19, 2014; Accepted for publication September 22, 2014.
PURPOSE: This paper examines the findings from an exit interview with a cardiometabolic health nurse (CHN) following a 26-week trial. DESIGN AND METHODS: The CHN participated in a semi-structured exit interview following completion of the 26-week trial. Applied thematic analysis was used to identify themes contained in the resultant transcript. FINDINGS: Contrary to the literature, the CHN did not consider additional training necessary to undertake the role. The CHN felt additional information regarding the research implications of the trial and greater organizational support would contribute to better consumer and health service outcomes. PRACTICE IMPLICATIONS: While personally rewarding, more can be done to help the CHN role reach its potential.
doi: 10.1111/ppc.12091
Recent studies repeatedly emphasize the poorer physical health of people with serious mental illness (SMI) compared with the general population (Scott et al., 2012; Vancampfort, Correll et al., 2013; Vancampfort, Wampers et al., 2013). While psychotropic medications contribute to this scenario, so do the poorer physical health behaviors of people with SMI. Studies typically report that people with SMI have low levels of physical activity (Vancampfort et al., 2011), poor diets (Simonelli-Muñoz et al., 2012), higher rates of substance misuse such as tobacco, alcohol, and illicit drugs (Ashton, Rigby, & Galletly, 2013; Berk, Sarris, Coulson, & Jacka, 2013), and are more likely to engage in risky sexual behaviors (Davidson et al., 2001). As a consequence, people with SMI experience a poorer quality of life and early mortality compared with the general population (Hoang, Goldacre, & Stewart, 2013; Lawrence, Kisely, & Pais, 2010). People with SMI also experience significant healthcare disparities that may contribute to these inequities in physical 268
health, quality of life, and mortality (Duhoux, Fournier, Gauvin, & Roberge, 2012; Scott & Happell, 2012). These include a lower likelihood of receiving routine blood tests for cholesterol or blood glucose (Tully et al., 2012) and a lower likelihood of screening for cancer or infectious diseases (Happell, Scott, & Platania-Phung, 2012). Nurses working in mental health are often at the front line of health care for people with SMI and face the challenge of managing the mental health and physical healthcare needs of consumers. While nurses are acutely aware of the physical healthcare needs of people with SMI, they are often under trained, lack the resources, inadequately prepared, and lack the time to provide an adequate standard of physical health care (Happell, Scott, Nankivell, & Platania-Phung, 2013b; Robson & Haddad, 2012). A dedicated nursing role addressing the poor physical health of people with SMI has been previously proposed (Brunero & Lamont, 2009). Such a role would be principally Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
Lessons Learned From the Trial of a Cardiometabolic Health Nurse
responsible for coordinating the prevention, detection, and treatment of cardiometabolic disorders. Similar roles developed internationally have been successful in improving primary care linkages for people with SMI and are shown to be cost-effective (Griswold, Homish, Pastore, & Leonard, 2010). However, trials of a specialist cardiometabolic health nurse (CHN) role in Australia are lacking. To examine the potential for such a role in an Australian context, we recently completed a 26-week randomized controlled trial (RCT) of a specialist CHN in a regional mental health service in Queensland, Australia. Implementation of the CHN Role Two candidates applied for and were subsequently interviewed for the CHN position. Neither of the candidates had prior research training or experience with clinical trials. The CHN recruited to the position was a registered nurse, educated as a general nurse, with more than 10 years of experience in community and inpatient mental health settings, but no formal qualification in mental health nursing. The CHN was employed in the mental health service where the trial was undertaken and was familiar with the service and staff. Following recruitment, the research team met with the CHN and Director of Nursing to outline the scope of the role in greater detail. We familiarized the CHN with the array of survey instruments and methods for data acquisition. Regular meetings were scheduled to ensure a smooth transition into the role and to address any concerns by either party. Care was taken to ensure service staff and clinicians were aware of the trial and its purpose. We held formal meetings with clinical staff and health service management. Researchers, clinical, and other mental health service staff collaborated to develop strategies for participant recruitment and referral to the CHN. Feedback from clinicians and management confirmed the need for such a role to address the physical health of mental health consumers, and that the outcomes would be of great interest. The CHN established links with local medical practices to identify those conveniently located close to public transport, offered a bulk billing service (covered by Medicare—a federally funded program which provides free or subsidized healthcare services), and had both male and female doctors. The CHN also identified local allied health clinics, including podiatry, physiotherapy, and dietetics services, as potential referral pathways. The CHN was responsible for assessing for risk factors for cardiometabolic disease such as hypertension, obesity, sedentary behavior, poor dietary habits, smoking, and alcohol misuse. The CHN also coordinated the physical health care of mental health consumers by referring them to other health professionals, including general practitioners, exercise physiologists, and dieticians, as necessary. The CHN arranged at Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
least two appointments with each participant: at baseline to undertake an initial assessment, arrange additional care and provide health behavior advice; and at 24–26 weeks, to reassess and follow-up on referral outcomes. Additional CHN appointments were arranged as deemed necessary to improve physical health outcomes. For novel positions such as the CHN to be acceptable in mental health settings, nurses and other health professionals must support the intervention. A survey of nurses showed strong support for the role, with evidence of potential benefits to mental health consumers outweighing possible costs (Happell, Stanton, Hoey, & Scott, 2014a). This finding is consistent with larger samples within the Australian nursing community (Happell, Scott, & Platania-Phung, 2013). Any ambivalence toward the role at the commencement of the study was reduced somewhat by trial completion, with increased support confirming the value of the CHN role for nurses working in mental health (Happell, Stanton, Hoey, & Scott, 2014b). This is the first known RCT of a CHN in Australia.As part of the study evaluation process, we sought the views of the CHN regarding the role to further develop the position for future studies and broader implementation. The aims of this paper are 2-fold.Firstly,we report the outcomes of a semi-structured exit interview with the CHN employed for this recent RCT. Secondly, we apply the lessons learned from our CHN to the future development and implementation of the role. Methods Approach A qualitative, exploratory approach guided the interview process (Stebbens, 2001). This approach offers the scope and opportunity for the participant to inform the research issue by sharing experiences and opinions. Setting and Participant The interview was undertaken with the CHN who constituted the intervention in the research study. The intervention site was a rural mental health service in Queensland, Australia. Procedure A single, semi-structured telephone exit interview was undertaken with the CHN following completion of the intervention. Specifically, we queried the perceived benefit of the position, the manner in which the position was implemented, and the future development of the role. These views are vitally important as they provide a frontline perspective of the manner in which the position has been developed and implemented thus far, and how additional support may be offered 269
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for future studies. This technique is widely used to provide information regarding current service practices, management, and training (Giacalone, Jurkiewicz, & Knouse, 2003). The exit interview addressed the following topics: 1. Initial understanding of the role of the CHN; 2. Organizational support; 3. Consumers, service, and personal outcomes; 4. Effect of the position on your view of the physical health of people with mental illness. The exit interview was recorded using a portable digital electronic recording device and the audio file was transcribed by a transcription service independent to the mental health service and research center. The questions within each theme were open ended, and further probing or clarifying questions were asked if necessary. Data Analysis Applied thematic analysis (Guest, MacQueen, & Namey, 2012) was used to analyze the interview transcript. This qualitative approach was deemed appropriate for this study as a method of identifying, analyzing, and describing themes within the data. We used an inductive analysis because there were no previous studies describing the views of CHNs (Vaismoradi, Turunen, & Bondas, 2013). Two researchers (DH, RS) read the transcript and highlighted the passages that are of interest to the research question. These passages were coded to themes, according to commonalities and differences. The resulting themes from each researcher were compared and refined until consensus was achieved. Ethics Ethical approval for this exit interview was provided by the health service and University Human Research Ethics Committees. The CHN provided verbal informed consent to participate in this exit interview. She was informed that her participation in the interview was voluntary and she was free to decline involvement or to withdraw at any stage. Results Two main themes were identified: establishment of the program and program outcomes. The subthemes that emerged when examining program establishment focused around the role of the CHN, stakeholder orientation, and consumer recruitment. The subthemes in program outcomes focused on outcomes for consumers, the health service, and the CHN. Establishment of the Program Role of the CHN. Prior to appointment, the CHN had extensive general nursing experience and more than 10 years of 270
experience in community and inpatient mental health settings; however, she did not have specialist qualifications in mental health nursing or chronic disease management. The CHN admitted to not being familiar with the new role prior to commencement and believed it would be an extension of a general nursing role. The CHN perceived cardiometabolic assessments as something that: . . . basically as a nurse in general ward we do it all the time anyway, it’s just part of our day to day job. The CHN reported the role as more of a general nursing focus, rather than mental health, and that some of the other nurses in the mental health services considered themselves to be more“psych trained,”a possible explanation for the neglect of physical health care. The CHN’s view was that specific training was not required to undertake the role. However, skills in communication and the development of excellent rapport with consumers were deemed essential. The CHN reported that other staff perceived the CHN role as a provider of information, particularly with the health service’s implementation of a centralized database that records cardiometabolic data. The collection of data such as blood pressure, weight, and body mass index might sometimes be overlooked, so the CHN reported that the role made an important contribution by gathering this information. Stakeholder Orientation. While care was taken to establish the CHN position through numerous meetings between key stakeholders, some staff within the organization were not aware of the new position and their obligations regarding referral and communication. Repeatedly explaining the program and its needs was regarded by the CHN as a “bit of a setback.” The CHN felt that the support from the health service was not sufficient in the early stages, but increased as the role progressed. The support from the University was described as beneficial at all stages of the intervention. Consumer Recruitment. The CHN cited that a significant barrier to performing the role was initial resistance from the consumers referred for cardiometabolic screening. The inherent characteristics of consumers made it challenging, with the CHN stating that some were not interested in continuing after their initial consultation, which attributed to the consumers’ mental health status: A couple were very nervous about trying anything new, where you [consumers] basically are leaving the house. Others were not interested in completing the survey material, with the mention of the University and emphasis on the research study possibly being a deterrent. I think that it was research meant that it was a little bit too much for them to understand. Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
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Program Outcomes Consumer Outcomes. The CHN was optimistic about the positive outcomes the intervention produced for the consumers: I could see that they had lost a little bit of weight. They were exercising; they were trying to eat better. They were trying to improving their diet and were generally quite pleased to see me . . . the consumers appreciated the one on one support of actually assisting them with . . ., little tips on what they could do to improve their exercise. In addition to nutritional and physical activity counseling, the CHN reported consumers receiving blood and other health screening tests as another positive. Hospital and Health Service Outcomes. A positive outcome reported by the CHN is that the mental health service has re-introduced more stringent cardiometabolic monitoring requirements for mental health inpatients, with information entered into a centralized database for access by health service staff. The CHN intervention did not necessarily drive this initiative, but the awareness of its importance was perhaps highlighted. The CHN suggested that a dedicated CHN role servicing mental health inpatients would be an ideal scenario. CHN Outcomes. The CHN reported the position to be personally and professionally worthwhile, reporting substantially increased confidence as a result of the position. In addition, the CHN valued new experiences such as being involved in research and surveys, monitoring in the community (as opposed to inpatients), and seeing mental health clients who were well. Discussion Role of the CHN The CHN reported having minimal understanding of the role initially, perceiving it as an extension of a general nursing role. However, cardiometabolic assessments encompass more than just physical assessment, and should also include psychological, behavioral, and environmental attributes that contribute to cardiometabolic disease. These behavioral factors may include physical activity, dietary habits, smoking status, and alcohol use; the combined effect of which may not be seen with physical measurements alone and which are not routinely performed by nurses working in mental health (Howard & Gamble, 2010; Hyland, Judd, Davidson, Jolley, & Hocking, 2003). This opinion may reflect the view that nurses with specialist mental health preparation, but no generalist background, may not be well equipped for physical care. The Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
compartmentalization of mental and physical health care has been identified as a possible reason why many mental health nurses are not skilled to undertake metabolic monitoring (Sinding et al., 2013). While not an uncommon view (Happell, Scott, Platania-Phung, & Nankivell, 2012), at the same time it is not supported by the literature. No evidence is available to support the improvement of physical health care within mental health services following the introduction of generalist preparation for nurses three decades ago (Happell & Cutcliffe, 2011). An established CHN role has the potential to address underlying issues and perform a proactive, preventative role (Brunero & Lamont, 2009; Happell et al., 2013). Part of the CHN role in this study included referring clients to preventative screening services (such as routine blood tests and screening for cancer). These services are underutilized by people with SMI (Happell et al., 2012; Tully et al., 2012). Yet this information was inconsistently recorded as baseline cardiometabolic data by the CHN. However, the referrals and lifestyle counseling performed by a CHN are a service that would develop and improve with the maturation and continuance of the CHN initiative. In the future, alignment of the CHN role with a recovery-focused or patient-centered model of care may result in greater consumer participation and acceptance by health services. Stakeholder Orientation There were two issues with key stakeholders and the establishment of the CHN role. Firstly, the CHN reported some difficulty in securing support for referrals from case managers and their willingness to support the research project. This may reflect the case managers’ lack of familiarity with research of this type, despite significant support at management and nursing director level. The literature shows that case managers are crucial to the success of research studies in that they need to be able to relate their practice to the trial and understand it. Without such understanding, they can become protective of their clients and apply their own eligibility criteria (Povlsen & Borup, 2011). As an alternative,nurses and other staff may not see research as part of their core business and lack the skills to undertake, critique, or implement the findings from research as identified in the literature (Breimaier, Halfens, & Lohrmann, 2011; McMaster, Jammali-Blasi, Andersson-Noorgard, Cooper, & McInnes, 2013). Excessive workloads and lack of time are also commonly reported as barriers to research participation across multiple health professional domains (Paget, Lilischkis, Morrow, & Caldwell, 2014). Interestingly, similar barriers are reported to the implementation of evidence-based practice (Brown, Wickline, Ecoff, & Glaser, 2009) and in research utilization in nursing practice (Hutchinson & Johnston, 2004). The opportunity to undertake research training and the 271
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introduction of research mentors are strategies suggested to improve nurses’ capacity for research participation (McMaster et al., 2013); however in practice, this must be balanced against staffing levels and costs. The apparent reluctance of case managers and other nursing staff to fully engage with the CHN contrasts with the CHN’s view that the role was seen as a valuable source of information and this view is critical to the success of the role. Perhaps, the perceived usefulness of the data collected by the CHN increased as the program became more established. While this concept may support the views expressed in quantitative surveys of the view of nurses working in mental health regarding the CHN role, not all agree and some have expressed concerns over greater fragmentation of the nursing role (Happell et al., 2013). Thus, there is a critical need for health services intending to implement the CHN role to educate clinicians on the integral role played by the CHN. At the very least, this should include the CHN’s involvement in clinical case reviews, but could extend to the CHN developing and delivering interdisciplinary education sessions for the staff. The focus of such education might include the benefits not only to mental health consumers, but also to nursing and allied health staff in terms of reduced workloads. Secondly, the health service where the RCT was undertaken was transitioning through a period of restructure which impacted the conduct of the study and the capacity of the CHN to gain sufficient support of the other staff. While support was not present at all levels early in the CHN’s role, it did improve as the study progressed. The restructure hampered the commencement of the study and may have contributed to ongoing challenges with referral, recruitment, and retention of consumers to the trial. Organizational support and collaboration between disciplines are crucial to the successful implementation of nursing case management (Ursoniu, Vernic, Muntean, & Timar, 2012). Consumer Recruitment The CHN believes the role was appreciated by the consumers who participated in the trial, and the attrition rate was due to their illness, rather than the intervention. This view is supported by other studies which report difficulties with recruitment and retention because of illness symptoms, limited understanding of ethical considerations, and low motivation for participating in research (Jorgensen et al., 2014). Additionally, patients with mental illness and their case managers have misconceptions about RCTs and of “missing out,” which can further impact on recruitment (Howard, de Salis, Tomlin, Thornicroft, & Donovan, 2009). The CHN agreed that a service delivery approach, rather than a clinical trial approach, would increase consumer participation. This fits with Furimsky, Cheung, Dewa, and Zipursky’s (2008) strategy of streamlining and integrating clinical and research 272
assessments to present a less fragmented product to the consumer. When coupled with workload adjustments, this approach is also likely to reduce the barriers posed by nurses’ attitudes toward research, which contribute to poor participant recruitment (Fletcher, Gheorghe, Moore, Wilson, & Damery, 2012). Moreover, despite significant efforts, the CHN noted difficulties in arranging transport for participants to attend appointments. This proved a further barrier to consumer recruitment and engagement. Other researchers report success with financial compensation or the payment of transportation costs (Furimsky et al., 2008), so taxi vouchers or other subsidies could assist with retention. Collectively, the lack of familiarity with interventional research and transport difficulties may have contributed to difficulties in participant recruitment and retention, and subsequently achieving the full potential of the CHN role. Consumer Outcomes The CHN was well informed as to the expected outcomes for study participants, citing improvements in cardiometabolic risk factors such as weight loss and improved physical activity levels. However, the research outcomes were not so clearly articulated. The CHN’s responses centered on patientfocused outcomes. This likely reflects the level of research experience of the CHN. As a short-term trial in a regional area, we were not able to recruit a person with the appropriate clinical and research experience. To circumvent this in future studies, the development and implementation of a procedure document outlining the scope and anticipated duties for the role, use of referral pathways, and documentation of consultation notes, including a model for continual service improvement, is considered essential. An unanticipated benefit for the researchers, but identified by the CHN, was how the consumers valued the one-on-one attention to their physical health. Similar studies show that patient-centered consultations lead to increased treatment adherence (Gearing, Townsend, Elkins, El-Bassel, & Osterberg, 2014; Thompson & McCabe, 2012). This is critical for people with SMI as a myriad of factors such as antipsychotic-induced weight gain and poor clinician–patient communication contribute to poor overall treatment adherence (McCloughen & Foster, 2011; Sajatovic et al., 2011; Thompson & McCabe, 2012). Low adherence to treatment is also linked to poorer prognosis (Misdrahi, Petit, Blanc, Bayle, & Llorca, 2012) and a lower likelihood of participation in research (Sajatovic et al., 2011). Implementing effective recovery-focused and patient-centered care in mental health settings can represent significant challenges to healthcare systems, however, and integrated care models represent one strategy with the potential to overcome the “silos” of care currently available (Patel et al., 2013). Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
Lessons Learned From the Trial of a Cardiometabolic Health Nurse
Hospital and Health Service Outcomes The CHN believed that the conduct of this RCT has coincided well with the introduction of mandatory metabolic monitoring on the inpatient ward.The view expressed was that this role should be the domain of one person who would undertake chart reviews and identify those at risk of cardiometabolic complications because many nurses are not well trained to undertake metabolic monitoring. The CHN did not discuss the issue of training for all nurses. A recent review suggests that nurses working in mental health are in need of, and are willing to undertake, further training in physical health care for people with SMI (Blythe & White, 2012). The findings of Blythe and White (2012) are strongly supported in a more recent study investigating the training needs of nurses working in mental health; however, the support of the organization in the delivery and implementation of training programs is deemed critical (Happell, Scott, Nankivell, & Platania-Phung, 2013a). It would appear that for the CHN role to be successful, potential CHNs should possess considerable nursing experience in mental health, in addition to general training. These skills would facilitate effective communication characteristic of effective mental health nursing practice (Ennis, Happell, Broadbent, & Reid-Searl, 2013) and facilitate a holistic approach to practice (Povlsen & Borup, 2011). Underpinning this is the shift toward the use of motivational interviewing skills in the management of chronic illness in people with (Lawn et al., 2007) and without (Gabbay et al., 2013) mental illness to affect positive selfmanagement. Future CHNs should recognize the need for, and be willing to undergo, additional training or up-skilling as necessary. At an organizational level, this should be included in the position description and be regularly reviewed. With respect to connecting mental health consumers with community-based services, the CHN did agree that the development of a database of community contacts to link consumers with resources to assist in achieving physical health goals was important, but, again, did not feel that specific training was required for this task. CHN Outcomes The CHN reported a degree of personal success associated with the role, which appeared to be aligned with the success of study participants achieving their goals such as weight loss or increased physical activity. Furthermore, engagement in research was reported to be a significant personal achievement, resulting in a valuable learning experience not otherwise available. Implications for Nursing Practice There are lessons from the trial of our CHN which can inform practice. Firstly, the qualitative findings from this Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
exit interview suggest that the CHN role can be both rewarding and challenging. Importantly for implementation, the position requires health service support with respect to ongoing training and the support of other nurses, case managers, and clinicians with a clear understanding of the role and its potential. Additionally, identifying and providing staff with the requisite skills and attributes over and above the clinical skillset such as motivational interviewing, chronic disease management, and educational delivery skills may ease the transition from general or mental health nursing to the CHN position. Implementation of the CHN role as “usual care” should be founded on a framework of good processes, including identifying and addressing multiple barriers, assessing and interpreting quality healthcare outcomes, and attending to policy changes (Powell et al., 2012). Implications for Mental Health Nursing Practice The contributions of our CHN in evaluating the role will inform the research, development, and implementation of similar positions elsewhere. Future studies of the CHN position should seek to clarify the role description, including anticipated duties pertaining to both the clinical and research arm of the study using written procedure and protocol documentation. The experiences of the CHN in our trial have made a significant contribution to this aspect of future trials by examining the views of the CHN and how this role may be positioned as “usual care.” However, future studies will need to examine and utilize these findings in the context of the unique healthcare setting in which the CHN will be implemented. For future trials, the availability of a detailed procedure document will reduce the ambiguity of the research aspect of the role and ensure the CHN is sufficiently informed as to how the role may differ from general or mental health nursing. In this regard, the provision of the supplementary skillset highlighted earlier may facilitate the transition from general or mental health nursing to the CHN role. This training should include specific guidance on collection of information needed for clinical and consumer decision-making in addition to informing research outputs. A future trial of the CHN role is warranted to determine the impact of the role with a larger sample of consumers. Learnings from the current study suggest that the CHN should have qualifications and expertise in both general and mental health nursing. Additional training specific to the requirements of the role should also be provided. An important lesson from the trial of our CHN is to maximize recruitment and retention of consumers; framing the intervention as a “service delivery trial” should be explored. Further, we recommend that a summary of the relevant literature on the cardiometabolic health and lifestyle behaviors of 273
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people with SMI be prepared to ensure that the CHN is aware of contemporary views on the topic. We have also learned the critical importance of organizational support for the successful implementation of the CHN role as an interventional trial and it is likely that this applies equally to its adoption as a permanent role. Therefore, analysis of the physical and human resources such as office space, administrative support, and communication pathways is critical. Finally, future studies should consider the costeffectiveness of the role given the increasing demand on budgetary decisions in health services delivery. Conclusions This is the first review of the CHN role as seen from the perspective of a nurse undertaking this important role. While personally rewarding, greater research and health services organizational support are required for the role to fulfill its potential. Consumer consultation and education and the positioning of the intervention as a service delivery model may further contribute to its success. References Ashton, M., Rigby, A., & Galletly, C. (2013). What do 1000 smokers with mental illness say about their tobacco use? Australian and New Zealand Journal of Psychiatry, 47(7), 631–636. doi:10.1177/0004867413482008 Berk, M., Sarris, J., Coulson, C. E., & Jacka, F. N. (2013). Lifestyle management of unipolar depression. Acta Psychiatrica Scandinavica, 127(Suppl. 443), 38–54. doi:10.1111/acps.12124 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(3), 193–201. doi:10.1111/j.1447-0349.2011.00792.x Breimaier, H. E., Halfens, R. J. G., & Lohrmann, C. (2011). Nurses’ wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria. Journal of Clinical Nursing, 20(11–12), 1744–1756. doi:10.1111/j.1365-2702.2010.03491.x Brown, C. E., Wickline, M. A., Ecoff, L., & Glaser, D. (2009). Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center. Journal of Advanced Nursing, 65(2), 371–381. doi:10.1111/j.1365-2648.2008.04878.x Brunero, S., & Lamont, S. (2009). Systematic screening for metabolic syndrome in consumers with severe mental illness. International Journal of Mental Health Nursing, 18(2), 144–150. doi:10.1111/j.1447-0349.2009.00595.x Davidson, S., Judd, F., Jolley, D., Hocking, B., Thompson, S., & Hyland, B. (2001). Risk factors for HIV/AIDS and hepatitis C among the chronic mentally ill. Australian and New Zealand Journal of Psychiatry, 35(2), 203–209.
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illness in Australia. International Journal of Mental Health Nursing, 22(5), 418–429. doi:10.1111/j.1447-0349.2012.00892.x Happell, B., Scott, D., Nankivell, J., & Platania-Phung, C. (2013a). Nurses’ views on training needs to increase provision of primary care for consumers with serious mental illness. Perspectives in Psychiatric Care, 49(3), 210–217. doi:10.1111/j.1744-6163.2012.00351.x Happell, B., Scott, D., Nankivell, J., & Platania-Phung, C. (2013b). Screening physical health? Yes! But . . .: Nurses’ views on physical health screening in mental health care. Journal of Clinical Nursing, 22(15–16), 2286–2297. doi:10.1111/j.1365-2702.2012.04325.x Happell, B., Stanton, R., Hoey, W., & Scott, D. (2014a). Development, validation and initial outcomes of a questionnaire to investigate the views of nurses working in a mental health setting regarding a cardiometabolic health nursing role. Archives of Psychiatric Nursing, 28, 123–127. Happell, B., Stanton, R., Hoey, W., & Scott, D. (2014b). Reduced ambivalence to the role of the cardiometabolic health nurse following a 6 month trial. Perspectives in Psychiatric Care. doi:10.1111/ppc.12066 Hoang, U., Goldacre, M. J., & Stewart, R. (2013). Avoidable mortality in people with schizophrenia or bipolar disorder in England. Acta Psychiatrica Scandinavica, 127(3), 195–201. doi:10.1111/acps.12045 Howard, L., & Gamble, C. (2010). Supporting mental health nurses to address the physical health needs of people with serious mental illness in acute inpatient care settings. Journal of Psychiatric and Mental Health Nursing, 18(2), 105–112. doi:10.1111/j.1365-2850.2010.01642.x Howard, L., de Salis, I., Tomlin, Z., Thornicroft, G., & Donovan, J. (2009). Why is recruitment to trials difficult? An investigation into recruitment difficulties in an RCT of supported employment in patients with severe mental illness. Contemporary Clinical Trials, 30(1), 40–46. doi:10.1016/j.cct.2008.07.007 Hutchinson, A. M., & Johnston, L. (2004). Bridging the divide: A survey of nurses’ opinions regarding barriers to, and facilitators of, research utilization in the practice setting. Journal of Clinical Nursing, 13(3), 304–315. doi:10.1046/j.1365-2702.2003.00865.x Hyland, B., Judd, F., Davidson, S., Jolley, D., & Hocking, B. (2003). Case managers’ attitudes to the physical health of their patients. Australian and New Zealand Journal of Psychiatry, 37(6), 710–714. Jorgensen, R., Munk-Jorgensen, P., Lysaker, P. H., Buck, K. D., Hansson, L., & Zoffmann, V. (2014). Overcoming recruitment barriers revealed high readiness to participate and low dropout rate among people with schizophrenia in a randomized controlled trial testing the effect of a Guided Self-Determination intervention. BMC Psychiatry, 14, 28. doi:10.1186/1471-244x-14-28 Lawn, S., Battersby, M. W., Pols, R. G., Lawrence, J., Parry, T., & Urukalo, M. (2007). The mental health expert patient: Findings from a pilot study of a generic chronic condition self-management programme for people with mental illness.
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International Journal of Social Psychiatry, 53(1), 63–74. doi:10.1177/0020764007075010 Lawrence, D., Kisely, S., & Pais, J. (2010). The epidemiology of excess mortality in people with mental illness. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 55(12), 752–760. McCloughen, A., & Foster, K. (2011). Weight gain associated with taking psychotropic medication: An integrative review. International Journal of Mental Health Nursing, 20(3), 202–222. doi:10.1111/j.1447-0349.2010.00721.x McMaster, R., Jammali-Blasi, A., Andersson-Noorgard, K., Cooper, K., & McInnes, E. (2013). Research involvement, support needs, and factors affecting research participation: A survey of mental health consultation liaison nurses. International Journal of Mental Health Nursing, 22(2), 154–161. doi:10.1111/j.1447-0349.2012.00857.x Misdrahi, D., Petit, M., Blanc, O., Bayle, F., & Llorca, P.-M. (2012). The influence of therapeutic alliance and insight on medication adherence in schizophrenia. Nordic Journal of Psychiatry, 66(1), 49–54. doi:10.3109/08039488.2011.598556 Paget, S. P., Lilischkis, K. J., Morrow, A. M., & Caldwell, P. H. Y. (2014). Embedding research in clinical practice: Differences in attitudes to research participation among clinicians in a tertiary teaching hospital. Internal Medicine Journal, 44(1), 86–89. doi:10.1111/imj.12330 Patel, V., Belkin, G. S., Chockalingam, A., Cooper, J., Saxena, S., & Unützer, J. (2013). Grand challenges: Integrating mental health services into priority health care platforms. PLoS Medicine, 10(5), e1001448. doi:10.1371/journal.pmed.1001448 Povlsen, L., & Borup, I. K. (2011). Holism in nursing and health promotion: Distinct or related perspectives?—A literature review. Scandinavian Journal of Caring Sciences, 25(4), 798–805. Powell, B. J., McMillen, J. C., Proctor, E. K., Carpenter, C. R., Griffey, R. T., Bunger, A. C., . . . York, J. L. (2012). A compilation of strategies for implementing clinical innovations in health and mental health. Medical Care Research and Review, 69(2), 123–157. doi:10.1177/1077558711430690 Robson, D., & Haddad, M. (2012). Mental health nurses’ attitudes towards the physical health care of people with severe and enduring mental illness: The development of a measurement tool. International Journal of Nursing Studies, 49(1), 72–83. doi:10.1016/j.ijnurstu.2011.07.011 Sajatovic, M., Levin, J., Fuentes-Casiano, E., Cassidy, K. A., Tatsuoka, C., & Jenkins, J. H. (2011). Illness experience and reasons for nonadherence among individuals with bipolar disorder who are poorly adherent with medication. Comprehensive Psychiatry, 52(3), 280–287. doi:10.1016/j.comppsych.2010.07.002 Scott, D., & Happell, B. (2012). Utilization and perceptions of primary health care services in Australian adults with mental illness. Population Health Management, 16(3), 208–213. doi:10.1089/pop.2012.0018 Scott, D., Burke, K., Williams, S., Happell, B., Canoy, D., & Ronan, K. (2012). Increased prevalence of chronic physical health disorders in Australians with diagnosed mental illness.
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Australian and New Zealand Journal of Public Health, 36(5), 483–486. doi:10.1111/j.1753-6405.2012.00916.x Simonelli-Muñoz, A. J., Fortea, M. I., Salorio, P., Gallego-Gomez, J. I., Sánchez-Bautista, S., & Balanza, S. (2012). Dietary habits of patients with schizophrenia: A self-reported questionnaire survey. International Journal of Mental Health Nursing, 21(3), 220–228. doi:10.1111/j.1447-0349.2012.00821.x Sinding, C., Watt, L., Miller, P., Silliker, J., Lawson, L., Kislinsky, C., . . . McGillicuddy, P. (2013). Stigmas and silos: Social workers’ accounts of care for people with serious mental illness and cancer. Social Work in Mental Health, 11(3), 288–309. doi:10.1080/15332985.2012.758075 Stebbens, R. (2001). Exploratory research in the social sciences: Qualitative research methods (Vol. 48). London: Sage Publications. Thompson, L., & McCabe, R. (2012). The effect of clinician-patient alliance and communication on treatment adherence in mental health care: A systematic review. BMC Psychiatry, 12(1), 87. Tully, J., Sim, C., Hemani, R., Munir, M., Khalil, N., & Fahy, S. (2012). Audit of monitoring of the parameters of metabolic syndrome in patients on clozapine. The Psychiatrist, 36(12), 466–469. doi:10.1192/pb.bp.111.037994 Ursoniu, S., Vernic, C., Muntean, C., & Timar, B. (2012). Nursing case management: Identifying, coordinating and monitoring
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the implementation of care services for patients. Annals: Computer Science Series, 10(2), 34–38. Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing & Health Sciences, 15(3), 398–405. doi:10.1111/nhs.12048 Vancampfort, D., Probst, M., Scheewe, T., Maurissen, K., Sweers, K., Knapen, J., & De Hert, M. (2011). Lack of physical activity during leisure time contributes to an impaired health related quality of life in patients with schizophrenia. Schizophrenia Research, 129(2–3), 122–127. doi:10.1016/j.schres.2011.03.018 Vancampfort, D., Correll, C. U., Wampers, M., Sienaert, P., Mitchell, A. J., De Herdt, A., . . . De Hert, M. (2013). Metabolic syndrome and metabolic abnormalities in patients with major depressive disorder: A meta-analysis of prevalences and moderating variables. Psychological Medicine, 44(10), 2017–2028. doi:10.1017/S0033291713002778 Vancampfort, D., Wampers, M., Mitchell, A. J., Correll, C. U., De Herdt, A., Probst, M., & De Hert, M. (2013). A meta-analysis of cardio-metabolic abnormalities in drug naive, first-episode and multi-episode patients with schizophrenia versus general population controls. World Psychiatry, 12(3), 240–250. doi:10.1002/wps.20069
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Perspectives in Psychiatric Care
ISSN 0031-5990
Lessons Learned From the Trial of a Cardiometabolic Health Nurse Brenda Happell, PhD, Danya Hodgetts, PhD, Robert Stanton, BHMSC (Hons), Freyja Millar, RN, MNP, Chris Platania Phung, PhD, and David Scott, PhD Brenda Happell, PhD, is Professor of Mental Health Nursing, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Danya Hodgetts, PhD, is Adjunct Research Fellow, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Robert Stanton, BHMSc (Hons), is Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Freyja Millar, RN, MNP, is Mental Health Nurse, Eastern Health, Melbourne, Victoria, Australia; Chris Platania Phung, PhD, is Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; David Scott, PhD, is Adjunct Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia and is AIMSS Postdoctoral Research Fellow, NorthWest Academic Centre, University of Melbourne, Melbourne, Victoria, Australia.
Search terms: Physical health care, severe mental illness, mental health nursing, chronic illness Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no actual or potential conflicts of interest. First Received July 27, 2014; Final Revision received September 19, 2014; Accepted for publication September 22, 2014.
PURPOSE: This paper examines the findings from an exit interview with a cardiometabolic health nurse (CHN) following a 26-week trial. DESIGN AND METHODS: The CHN participated in a semi-structured exit interview following completion of the 26-week trial. Applied thematic analysis was used to identify themes contained in the resultant transcript. FINDINGS: Contrary to the literature, the CHN did not consider additional training necessary to undertake the role. The CHN felt additional information regarding the research implications of the trial and greater organizational support would contribute to better consumer and health service outcomes. PRACTICE IMPLICATIONS: While personally rewarding, more can be done to help the CHN role reach its potential.
doi: 10.1111/ppc.12091
Recent studies repeatedly emphasize the poorer physical health of people with serious mental illness (SMI) compared with the general population (Scott et al., 2012; Vancampfort, Correll et al., 2013; Vancampfort, Wampers et al., 2013). While psychotropic medications contribute to this scenario, so do the poorer physical health behaviors of people with SMI. Studies typically report that people with SMI have low levels of physical activity (Vancampfort et al., 2011), poor diets (Simonelli-Muñoz et al., 2012), higher rates of substance misuse such as tobacco, alcohol, and illicit drugs (Ashton, Rigby, & Galletly, 2013; Berk, Sarris, Coulson, & Jacka, 2013), and are more likely to engage in risky sexual behaviors (Davidson et al., 2001). As a consequence, people with SMI experience a poorer quality of life and early mortality compared with the general population (Hoang, Goldacre, & Stewart, 2013; Lawrence, Kisely, & Pais, 2010). People with SMI also experience significant healthcare disparities that may contribute to these inequities in physical 268
health, quality of life, and mortality (Duhoux, Fournier, Gauvin, & Roberge, 2012; Scott & Happell, 2012). These include a lower likelihood of receiving routine blood tests for cholesterol or blood glucose (Tully et al., 2012) and a lower likelihood of screening for cancer or infectious diseases (Happell, Scott, & Platania-Phung, 2012). Nurses working in mental health are often at the front line of health care for people with SMI and face the challenge of managing the mental health and physical healthcare needs of consumers. While nurses are acutely aware of the physical healthcare needs of people with SMI, they are often under trained, lack the resources, inadequately prepared, and lack the time to provide an adequate standard of physical health care (Happell, Scott, Nankivell, & Platania-Phung, 2013b; Robson & Haddad, 2012). A dedicated nursing role addressing the poor physical health of people with SMI has been previously proposed (Brunero & Lamont, 2009). Such a role would be principally Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
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responsible for coordinating the prevention, detection, and treatment of cardiometabolic disorders. Similar roles developed internationally have been successful in improving primary care linkages for people with SMI and are shown to be cost-effective (Griswold, Homish, Pastore, & Leonard, 2010). However, trials of a specialist cardiometabolic health nurse (CHN) role in Australia are lacking. To examine the potential for such a role in an Australian context, we recently completed a 26-week randomized controlled trial (RCT) of a specialist CHN in a regional mental health service in Queensland, Australia. Implementation of the CHN Role Two candidates applied for and were subsequently interviewed for the CHN position. Neither of the candidates had prior research training or experience with clinical trials. The CHN recruited to the position was a registered nurse, educated as a general nurse, with more than 10 years of experience in community and inpatient mental health settings, but no formal qualification in mental health nursing. The CHN was employed in the mental health service where the trial was undertaken and was familiar with the service and staff. Following recruitment, the research team met with the CHN and Director of Nursing to outline the scope of the role in greater detail. We familiarized the CHN with the array of survey instruments and methods for data acquisition. Regular meetings were scheduled to ensure a smooth transition into the role and to address any concerns by either party. Care was taken to ensure service staff and clinicians were aware of the trial and its purpose. We held formal meetings with clinical staff and health service management. Researchers, clinical, and other mental health service staff collaborated to develop strategies for participant recruitment and referral to the CHN. Feedback from clinicians and management confirmed the need for such a role to address the physical health of mental health consumers, and that the outcomes would be of great interest. The CHN established links with local medical practices to identify those conveniently located close to public transport, offered a bulk billing service (covered by Medicare—a federally funded program which provides free or subsidized healthcare services), and had both male and female doctors. The CHN also identified local allied health clinics, including podiatry, physiotherapy, and dietetics services, as potential referral pathways. The CHN was responsible for assessing for risk factors for cardiometabolic disease such as hypertension, obesity, sedentary behavior, poor dietary habits, smoking, and alcohol misuse. The CHN also coordinated the physical health care of mental health consumers by referring them to other health professionals, including general practitioners, exercise physiologists, and dieticians, as necessary. The CHN arranged at Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
least two appointments with each participant: at baseline to undertake an initial assessment, arrange additional care and provide health behavior advice; and at 24–26 weeks, to reassess and follow-up on referral outcomes. Additional CHN appointments were arranged as deemed necessary to improve physical health outcomes. For novel positions such as the CHN to be acceptable in mental health settings, nurses and other health professionals must support the intervention. A survey of nurses showed strong support for the role, with evidence of potential benefits to mental health consumers outweighing possible costs (Happell, Stanton, Hoey, & Scott, 2014a). This finding is consistent with larger samples within the Australian nursing community (Happell, Scott, & Platania-Phung, 2013). Any ambivalence toward the role at the commencement of the study was reduced somewhat by trial completion, with increased support confirming the value of the CHN role for nurses working in mental health (Happell, Stanton, Hoey, & Scott, 2014b). This is the first known RCT of a CHN in Australia.As part of the study evaluation process, we sought the views of the CHN regarding the role to further develop the position for future studies and broader implementation. The aims of this paper are 2-fold.Firstly,we report the outcomes of a semi-structured exit interview with the CHN employed for this recent RCT. Secondly, we apply the lessons learned from our CHN to the future development and implementation of the role. Methods Approach A qualitative, exploratory approach guided the interview process (Stebbens, 2001). This approach offers the scope and opportunity for the participant to inform the research issue by sharing experiences and opinions. Setting and Participant The interview was undertaken with the CHN who constituted the intervention in the research study. The intervention site was a rural mental health service in Queensland, Australia. Procedure A single, semi-structured telephone exit interview was undertaken with the CHN following completion of the intervention. Specifically, we queried the perceived benefit of the position, the manner in which the position was implemented, and the future development of the role. These views are vitally important as they provide a frontline perspective of the manner in which the position has been developed and implemented thus far, and how additional support may be offered 269
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for future studies. This technique is widely used to provide information regarding current service practices, management, and training (Giacalone, Jurkiewicz, & Knouse, 2003). The exit interview addressed the following topics: 1. Initial understanding of the role of the CHN; 2. Organizational support; 3. Consumers, service, and personal outcomes; 4. Effect of the position on your view of the physical health of people with mental illness. The exit interview was recorded using a portable digital electronic recording device and the audio file was transcribed by a transcription service independent to the mental health service and research center. The questions within each theme were open ended, and further probing or clarifying questions were asked if necessary. Data Analysis Applied thematic analysis (Guest, MacQueen, & Namey, 2012) was used to analyze the interview transcript. This qualitative approach was deemed appropriate for this study as a method of identifying, analyzing, and describing themes within the data. We used an inductive analysis because there were no previous studies describing the views of CHNs (Vaismoradi, Turunen, & Bondas, 2013). Two researchers (DH, RS) read the transcript and highlighted the passages that are of interest to the research question. These passages were coded to themes, according to commonalities and differences. The resulting themes from each researcher were compared and refined until consensus was achieved. Ethics Ethical approval for this exit interview was provided by the health service and University Human Research Ethics Committees. The CHN provided verbal informed consent to participate in this exit interview. She was informed that her participation in the interview was voluntary and she was free to decline involvement or to withdraw at any stage. Results Two main themes were identified: establishment of the program and program outcomes. The subthemes that emerged when examining program establishment focused around the role of the CHN, stakeholder orientation, and consumer recruitment. The subthemes in program outcomes focused on outcomes for consumers, the health service, and the CHN. Establishment of the Program Role of the CHN. Prior to appointment, the CHN had extensive general nursing experience and more than 10 years of 270
experience in community and inpatient mental health settings; however, she did not have specialist qualifications in mental health nursing or chronic disease management. The CHN admitted to not being familiar with the new role prior to commencement and believed it would be an extension of a general nursing role. The CHN perceived cardiometabolic assessments as something that: . . . basically as a nurse in general ward we do it all the time anyway, it’s just part of our day to day job. The CHN reported the role as more of a general nursing focus, rather than mental health, and that some of the other nurses in the mental health services considered themselves to be more“psych trained,”a possible explanation for the neglect of physical health care. The CHN’s view was that specific training was not required to undertake the role. However, skills in communication and the development of excellent rapport with consumers were deemed essential. The CHN reported that other staff perceived the CHN role as a provider of information, particularly with the health service’s implementation of a centralized database that records cardiometabolic data. The collection of data such as blood pressure, weight, and body mass index might sometimes be overlooked, so the CHN reported that the role made an important contribution by gathering this information. Stakeholder Orientation. While care was taken to establish the CHN position through numerous meetings between key stakeholders, some staff within the organization were not aware of the new position and their obligations regarding referral and communication. Repeatedly explaining the program and its needs was regarded by the CHN as a “bit of a setback.” The CHN felt that the support from the health service was not sufficient in the early stages, but increased as the role progressed. The support from the University was described as beneficial at all stages of the intervention. Consumer Recruitment. The CHN cited that a significant barrier to performing the role was initial resistance from the consumers referred for cardiometabolic screening. The inherent characteristics of consumers made it challenging, with the CHN stating that some were not interested in continuing after their initial consultation, which attributed to the consumers’ mental health status: A couple were very nervous about trying anything new, where you [consumers] basically are leaving the house. Others were not interested in completing the survey material, with the mention of the University and emphasis on the research study possibly being a deterrent. I think that it was research meant that it was a little bit too much for them to understand. Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
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Program Outcomes Consumer Outcomes. The CHN was optimistic about the positive outcomes the intervention produced for the consumers: I could see that they had lost a little bit of weight. They were exercising; they were trying to eat better. They were trying to improving their diet and were generally quite pleased to see me . . . the consumers appreciated the one on one support of actually assisting them with . . ., little tips on what they could do to improve their exercise. In addition to nutritional and physical activity counseling, the CHN reported consumers receiving blood and other health screening tests as another positive. Hospital and Health Service Outcomes. A positive outcome reported by the CHN is that the mental health service has re-introduced more stringent cardiometabolic monitoring requirements for mental health inpatients, with information entered into a centralized database for access by health service staff. The CHN intervention did not necessarily drive this initiative, but the awareness of its importance was perhaps highlighted. The CHN suggested that a dedicated CHN role servicing mental health inpatients would be an ideal scenario. CHN Outcomes. The CHN reported the position to be personally and professionally worthwhile, reporting substantially increased confidence as a result of the position. In addition, the CHN valued new experiences such as being involved in research and surveys, monitoring in the community (as opposed to inpatients), and seeing mental health clients who were well. Discussion Role of the CHN The CHN reported having minimal understanding of the role initially, perceiving it as an extension of a general nursing role. However, cardiometabolic assessments encompass more than just physical assessment, and should also include psychological, behavioral, and environmental attributes that contribute to cardiometabolic disease. These behavioral factors may include physical activity, dietary habits, smoking status, and alcohol use; the combined effect of which may not be seen with physical measurements alone and which are not routinely performed by nurses working in mental health (Howard & Gamble, 2010; Hyland, Judd, Davidson, Jolley, & Hocking, 2003). This opinion may reflect the view that nurses with specialist mental health preparation, but no generalist background, may not be well equipped for physical care. The Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
compartmentalization of mental and physical health care has been identified as a possible reason why many mental health nurses are not skilled to undertake metabolic monitoring (Sinding et al., 2013). While not an uncommon view (Happell, Scott, Platania-Phung, & Nankivell, 2012), at the same time it is not supported by the literature. No evidence is available to support the improvement of physical health care within mental health services following the introduction of generalist preparation for nurses three decades ago (Happell & Cutcliffe, 2011). An established CHN role has the potential to address underlying issues and perform a proactive, preventative role (Brunero & Lamont, 2009; Happell et al., 2013). Part of the CHN role in this study included referring clients to preventative screening services (such as routine blood tests and screening for cancer). These services are underutilized by people with SMI (Happell et al., 2012; Tully et al., 2012). Yet this information was inconsistently recorded as baseline cardiometabolic data by the CHN. However, the referrals and lifestyle counseling performed by a CHN are a service that would develop and improve with the maturation and continuance of the CHN initiative. In the future, alignment of the CHN role with a recovery-focused or patient-centered model of care may result in greater consumer participation and acceptance by health services. Stakeholder Orientation There were two issues with key stakeholders and the establishment of the CHN role. Firstly, the CHN reported some difficulty in securing support for referrals from case managers and their willingness to support the research project. This may reflect the case managers’ lack of familiarity with research of this type, despite significant support at management and nursing director level. The literature shows that case managers are crucial to the success of research studies in that they need to be able to relate their practice to the trial and understand it. Without such understanding, they can become protective of their clients and apply their own eligibility criteria (Povlsen & Borup, 2011). As an alternative,nurses and other staff may not see research as part of their core business and lack the skills to undertake, critique, or implement the findings from research as identified in the literature (Breimaier, Halfens, & Lohrmann, 2011; McMaster, Jammali-Blasi, Andersson-Noorgard, Cooper, & McInnes, 2013). Excessive workloads and lack of time are also commonly reported as barriers to research participation across multiple health professional domains (Paget, Lilischkis, Morrow, & Caldwell, 2014). Interestingly, similar barriers are reported to the implementation of evidence-based practice (Brown, Wickline, Ecoff, & Glaser, 2009) and in research utilization in nursing practice (Hutchinson & Johnston, 2004). The opportunity to undertake research training and the 271
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introduction of research mentors are strategies suggested to improve nurses’ capacity for research participation (McMaster et al., 2013); however in practice, this must be balanced against staffing levels and costs. The apparent reluctance of case managers and other nursing staff to fully engage with the CHN contrasts with the CHN’s view that the role was seen as a valuable source of information and this view is critical to the success of the role. Perhaps, the perceived usefulness of the data collected by the CHN increased as the program became more established. While this concept may support the views expressed in quantitative surveys of the view of nurses working in mental health regarding the CHN role, not all agree and some have expressed concerns over greater fragmentation of the nursing role (Happell et al., 2013). Thus, there is a critical need for health services intending to implement the CHN role to educate clinicians on the integral role played by the CHN. At the very least, this should include the CHN’s involvement in clinical case reviews, but could extend to the CHN developing and delivering interdisciplinary education sessions for the staff. The focus of such education might include the benefits not only to mental health consumers, but also to nursing and allied health staff in terms of reduced workloads. Secondly, the health service where the RCT was undertaken was transitioning through a period of restructure which impacted the conduct of the study and the capacity of the CHN to gain sufficient support of the other staff. While support was not present at all levels early in the CHN’s role, it did improve as the study progressed. The restructure hampered the commencement of the study and may have contributed to ongoing challenges with referral, recruitment, and retention of consumers to the trial. Organizational support and collaboration between disciplines are crucial to the successful implementation of nursing case management (Ursoniu, Vernic, Muntean, & Timar, 2012). Consumer Recruitment The CHN believes the role was appreciated by the consumers who participated in the trial, and the attrition rate was due to their illness, rather than the intervention. This view is supported by other studies which report difficulties with recruitment and retention because of illness symptoms, limited understanding of ethical considerations, and low motivation for participating in research (Jorgensen et al., 2014). Additionally, patients with mental illness and their case managers have misconceptions about RCTs and of “missing out,” which can further impact on recruitment (Howard, de Salis, Tomlin, Thornicroft, & Donovan, 2009). The CHN agreed that a service delivery approach, rather than a clinical trial approach, would increase consumer participation. This fits with Furimsky, Cheung, Dewa, and Zipursky’s (2008) strategy of streamlining and integrating clinical and research 272
assessments to present a less fragmented product to the consumer. When coupled with workload adjustments, this approach is also likely to reduce the barriers posed by nurses’ attitudes toward research, which contribute to poor participant recruitment (Fletcher, Gheorghe, Moore, Wilson, & Damery, 2012). Moreover, despite significant efforts, the CHN noted difficulties in arranging transport for participants to attend appointments. This proved a further barrier to consumer recruitment and engagement. Other researchers report success with financial compensation or the payment of transportation costs (Furimsky et al., 2008), so taxi vouchers or other subsidies could assist with retention. Collectively, the lack of familiarity with interventional research and transport difficulties may have contributed to difficulties in participant recruitment and retention, and subsequently achieving the full potential of the CHN role. Consumer Outcomes The CHN was well informed as to the expected outcomes for study participants, citing improvements in cardiometabolic risk factors such as weight loss and improved physical activity levels. However, the research outcomes were not so clearly articulated. The CHN’s responses centered on patientfocused outcomes. This likely reflects the level of research experience of the CHN. As a short-term trial in a regional area, we were not able to recruit a person with the appropriate clinical and research experience. To circumvent this in future studies, the development and implementation of a procedure document outlining the scope and anticipated duties for the role, use of referral pathways, and documentation of consultation notes, including a model for continual service improvement, is considered essential. An unanticipated benefit for the researchers, but identified by the CHN, was how the consumers valued the one-on-one attention to their physical health. Similar studies show that patient-centered consultations lead to increased treatment adherence (Gearing, Townsend, Elkins, El-Bassel, & Osterberg, 2014; Thompson & McCabe, 2012). This is critical for people with SMI as a myriad of factors such as antipsychotic-induced weight gain and poor clinician–patient communication contribute to poor overall treatment adherence (McCloughen & Foster, 2011; Sajatovic et al., 2011; Thompson & McCabe, 2012). Low adherence to treatment is also linked to poorer prognosis (Misdrahi, Petit, Blanc, Bayle, & Llorca, 2012) and a lower likelihood of participation in research (Sajatovic et al., 2011). Implementing effective recovery-focused and patient-centered care in mental health settings can represent significant challenges to healthcare systems, however, and integrated care models represent one strategy with the potential to overcome the “silos” of care currently available (Patel et al., 2013). Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
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Hospital and Health Service Outcomes The CHN believed that the conduct of this RCT has coincided well with the introduction of mandatory metabolic monitoring on the inpatient ward.The view expressed was that this role should be the domain of one person who would undertake chart reviews and identify those at risk of cardiometabolic complications because many nurses are not well trained to undertake metabolic monitoring. The CHN did not discuss the issue of training for all nurses. A recent review suggests that nurses working in mental health are in need of, and are willing to undertake, further training in physical health care for people with SMI (Blythe & White, 2012). The findings of Blythe and White (2012) are strongly supported in a more recent study investigating the training needs of nurses working in mental health; however, the support of the organization in the delivery and implementation of training programs is deemed critical (Happell, Scott, Nankivell, & Platania-Phung, 2013a). It would appear that for the CHN role to be successful, potential CHNs should possess considerable nursing experience in mental health, in addition to general training. These skills would facilitate effective communication characteristic of effective mental health nursing practice (Ennis, Happell, Broadbent, & Reid-Searl, 2013) and facilitate a holistic approach to practice (Povlsen & Borup, 2011). Underpinning this is the shift toward the use of motivational interviewing skills in the management of chronic illness in people with (Lawn et al., 2007) and without (Gabbay et al., 2013) mental illness to affect positive selfmanagement. Future CHNs should recognize the need for, and be willing to undergo, additional training or up-skilling as necessary. At an organizational level, this should be included in the position description and be regularly reviewed. With respect to connecting mental health consumers with community-based services, the CHN did agree that the development of a database of community contacts to link consumers with resources to assist in achieving physical health goals was important, but, again, did not feel that specific training was required for this task. CHN Outcomes The CHN reported a degree of personal success associated with the role, which appeared to be aligned with the success of study participants achieving their goals such as weight loss or increased physical activity. Furthermore, engagement in research was reported to be a significant personal achievement, resulting in a valuable learning experience not otherwise available. Implications for Nursing Practice There are lessons from the trial of our CHN which can inform practice. Firstly, the qualitative findings from this Perspectives in Psychiatric Care 51 (2015) 268–276 © 2014 Wiley Periodicals, Inc.
exit interview suggest that the CHN role can be both rewarding and challenging. Importantly for implementation, the position requires health service support with respect to ongoing training and the support of other nurses, case managers, and clinicians with a clear understanding of the role and its potential. Additionally, identifying and providing staff with the requisite skills and attributes over and above the clinical skillset such as motivational interviewing, chronic disease management, and educational delivery skills may ease the transition from general or mental health nursing to the CHN position. Implementation of the CHN role as “usual care” should be founded on a framework of good processes, including identifying and addressing multiple barriers, assessing and interpreting quality healthcare outcomes, and attending to policy changes (Powell et al., 2012). Implications for Mental Health Nursing Practice The contributions of our CHN in evaluating the role will inform the research, development, and implementation of similar positions elsewhere. Future studies of the CHN position should seek to clarify the role description, including anticipated duties pertaining to both the clinical and research arm of the study using written procedure and protocol documentation. The experiences of the CHN in our trial have made a significant contribution to this aspect of future trials by examining the views of the CHN and how this role may be positioned as “usual care.” However, future studies will need to examine and utilize these findings in the context of the unique healthcare setting in which the CHN will be implemented. For future trials, the availability of a detailed procedure document will reduce the ambiguity of the research aspect of the role and ensure the CHN is sufficiently informed as to how the role may differ from general or mental health nursing. In this regard, the provision of the supplementary skillset highlighted earlier may facilitate the transition from general or mental health nursing to the CHN role. This training should include specific guidance on collection of information needed for clinical and consumer decision-making in addition to informing research outputs. A future trial of the CHN role is warranted to determine the impact of the role with a larger sample of consumers. Learnings from the current study suggest that the CHN should have qualifications and expertise in both general and mental health nursing. Additional training specific to the requirements of the role should also be provided. An important lesson from the trial of our CHN is to maximize recruitment and retention of consumers; framing the intervention as a “service delivery trial” should be explored. Further, we recommend that a summary of the relevant literature on the cardiometabolic health and lifestyle behaviors of 273
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people with SMI be prepared to ensure that the CHN is aware of contemporary views on the topic. We have also learned the critical importance of organizational support for the successful implementation of the CHN role as an interventional trial and it is likely that this applies equally to its adoption as a permanent role. Therefore, analysis of the physical and human resources such as office space, administrative support, and communication pathways is critical. Finally, future studies should consider the costeffectiveness of the role given the increasing demand on budgetary decisions in health services delivery. Conclusions This is the first review of the CHN role as seen from the perspective of a nurse undertaking this important role. While personally rewarding, greater research and health services organizational support are required for the role to fulfill its potential. Consumer consultation and education and the positioning of the intervention as a service delivery model may further contribute to its success. References Ashton, M., Rigby, A., & Galletly, C. (2013). What do 1000 smokers with mental illness say about their tobacco use? Australian and New Zealand Journal of Psychiatry, 47(7), 631–636. doi:10.1177/0004867413482008 Berk, M., Sarris, J., Coulson, C. E., & Jacka, F. N. (2013). Lifestyle management of unipolar depression. Acta Psychiatrica Scandinavica, 127(Suppl. 443), 38–54. doi:10.1111/acps.12124 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(3), 193–201. doi:10.1111/j.1447-0349.2011.00792.x Breimaier, H. E., Halfens, R. J. G., & Lohrmann, C. (2011). Nurses’ wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria. Journal of Clinical Nursing, 20(11–12), 1744–1756. doi:10.1111/j.1365-2702.2010.03491.x Brown, C. E., Wickline, M. A., Ecoff, L., & Glaser, D. (2009). Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center. Journal of Advanced Nursing, 65(2), 371–381. doi:10.1111/j.1365-2648.2008.04878.x Brunero, S., & Lamont, S. (2009). Systematic screening for metabolic syndrome in consumers with severe mental illness. International Journal of Mental Health Nursing, 18(2), 144–150. doi:10.1111/j.1447-0349.2009.00595.x Davidson, S., Judd, F., Jolley, D., Hocking, B., Thompson, S., & Hyland, B. (2001). Risk factors for HIV/AIDS and hepatitis C among the chronic mentally ill. Australian and New Zealand Journal of Psychiatry, 35(2), 203–209.
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