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Perspectives in Psychiatric Care
ISSN 0031-5990
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd, MEd, PhD, Chris Platania-Phung, BA (Hons), David Scott, BHM (Hons), PhD, and Robert Stanton, BHM (Hons), PhD Candidate Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd, MEd, PhD, is an Engaged Research Chair in Mental Health Nursing, Director, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Chris Platania-Phung, BA (Hons), is a Research Fellow, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; David Scott, BHM (Hons), PhD, is a Post-Doctoral Research Fellow, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; and Robert Stanton, BHM (Hons), PhD Candidate, is a Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia
Search terms: Cardiometabolic health nurse, cardiovascular disease, diabetes care, mental health care, serious mental 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 January 7, 2014; Final Revision received April 22, 2014; Accepted for publication May 29, 2014
PURPOSE: A cardiometabolic specialist nursing role could potentially improve physical health of people with serious mental illness. DESIGN AND METHODS: A national survey of Australian nurses working in mental health settings investigated predictors of support for the role. FINDINGS: Predictors included belief in physical healthcare neglect, interest in training; higher perceived value of improving physical health care. PRACTICE IMPLICATIONS: The findings suggest that nurses see the cardiometabolic health nurse role as a promising initiative for closing gaps in cardiometabolic health care and skilling other nurses in mental health. However, as the majority of variance in cardiometabolic health nurse support was unexplained, more research is urgently needed on factors that explain differences in cardiometabolic health nurse endorsement.
doi: 10.1111/ppc.12077
Recent evidence shows the prevalence of cardiovascular disease, diabetes, and metabolic syndrome is higher for people diagnosed with serious mental illness (SMI) (Bressington et al., 2013; Ohaeri & Akanji, 2011). As a result, people with SMI experience higher mortality risk compared to the general population (De Hert, Schreurs, Vancampfort, & van Winkel, 2009; De Hert et al., 2011). Given the higher prevalence of cardiometabolic disease and higher mortality risk in people with SMI such as schizophrenia and bipolar disorder, people with SMI can benefit greatly from prevention and management strategies such as cardiometabolic screening and referral to primary care services, close attention to drug treatments, and support of health-behavior change (Meyer & Stahl, 2009). However, much improve162
ment to the current level of access to high-standard cardiometabolic and diabetes care services is needed. As inequalities in physical health care of people with SMI are systemic, multipronged strategies for better services are needed (Bradshaw & Pedley, 2012; Hardy & Thomas, 2012; Horvitz-Lennon, Kilbourne, & Pincus, 2006; Lawrence & Kisely, 2010; Meyer, Peteet, & Joseph, 2009; Sajatovic et al., 2011; Viron & Stern, 2010). To date, advances in reducing inequality in access to and quality of cardiometabolic care for people with SMI accessing mental health services are based on preliminary trials of new care models (Blythe & White, 2012; Faulkner, Soundy, & Lloyd, 2003; Happell, Davies, & Scott, 2012; van Hasselt, Krabbe, van Ittersum, Postma, & Loonen, 2013). Significant changes are still needed before there is Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
progress in reversing the inadequate cardiometabolic health care for people with SMI (Happell, Scott, et al., 2012). One potential strategy to improve the poorer physical health care of people with SMI is the inclusion of a nurse who assumes responsibility of coordinating physical health care to maximize the provision of systematic and comprehensive care in terms of both prevention and management. Brunero and Lamont (2009) described a new role focused on screening for risks as a “cardiometabolic mental health nurse consultant” (p. 148). Similarly, Happell, Scott, and Platania-Phung (2013) proposed the “cardiometabolic health nurse” (CHN) to integrate primary care and mental health care, and most of all, to ensure this high-risk group have access to primary care services that they may not receive or be able to access outside of mental health services. Specifically, the role of the CHN is to serve the following functions: (a) prevent and manage cardiometabolic-related conditions; (b) be a “go to” person for advice on physical health for nurses and other mental healthcare staff; (c) incorporate routine cardiometabolic screening into routine care of consumers with SMI (e.g., blood tests) as a main option for referral by nurses; and (d) provide health and lifestyle education to consumers with SMI. The title of cardiovascular health nurse is evident in some care settings (e.g., Wexler et al., 2004), but not in relation to care for people with mental illness. Although the clinical outcomes of a CHN role as part of mental healthcare services have not been examined, research on service evaluation for trials that included nurses providing primary care directly has demonstrated significant increases in delivery of physical health care (Druss et al., 2010; Griswold et al., 2005; Ohlsen, Peacock, & Smith, 2005; Simonelli-Munoz et al., 2012). CHNs who foster full commitment to cardiometabolic health care in mental health services may be of benefit for mental health consumers in Australia (both inpatient and community), as, similar to other parts of the world, these consumers experience shortfalls in access and quality care in that region (Coghlan, Lawrence, Holman, & Jablensky, 2001; Happell, Scott, et al., 2012; Hyland, Judd, Davidson, Jolley, & Hocking, 2003). In Australia, primary care and mental health services are administered separately (Duckett, 2007). The complexity of health care in Australia is due to the involvement of federal, state, and local governments (Duckett, 2007). Mental health services are a part of general healthcare services for each healthcare district (Australian Institute of Health and Welfare, 2013). Mental health service provision is comprised of public, private, and nongovernment community outreach. Public health services are available at no cost, while private services are usually paid for through individual health insurance (Australian Institute of Health and Welfare, 2013). The complexity of the healthcare system and the separation of mental health from primary care contribute to Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
the challenges in providing quality physical health services to people with mental illness. Under the current system, the CHN would be employed by the mental health service in a salaried position. The viability of actual implementation of the CHN is likely to depend on the extent of support for the role by mental health nurses. Common issues raised in regard to the introduction of new nursing roles include fragmentation of existing roles, de-skilling, and financial costs (Peplau, 2003). In light of these concerns, it is important to clarify that the CHN is intended to complement existing service delivery and facilitate cardiometabolic health care of patients with SMI within mental healthcare teams. The role is not the only strategy designed to address health inequities in the area of physical health care. Furthermore, the role is not intended to compensate fully for deficits in the knowledge and skill of nurses to provide physical healthcare (Happell, Scott, et al., 2013) views on whether a CHN would improve clinical care are likely to vary. Wright, Osborn, Nazareth, and King (2006) explored the proposal of a similar role in the United Kingdom for healthcare staff in community services. Findings included a number of advantages such as increased screening, and disadvantages such as costs. Countries such as the United States have trialed integrated care models and demonstrated increases in cardiometabolic care and reduction of cardiovascular risks (Druss & von Esenwein, 2006; Druss, Rohrbaugh, Levinson, & Rosenheck, 2001). Nurses have been instrumental to these approaches (e.g., Druss et al., 2010). Due to differences in mental healthcare delivery across countries, the generalizability of the findings of the Wright et al.’s (2006) study and integrated care models in the United States is limited, and so further research is required on how the CHN might be supported in Australia. In addition, a quantitative study with the purpose of identifying precursors to support for the role of the CHN would inform policy makers in understanding the reasons for support for the CHN role and the subsequent need for mental healthcare reform. To address this literature gap, we conducted a national survey on the views of nurses working in the mental health sector of Australia on the state of physical healthcare services and the role of nurses in improving services for people with SMI. Preliminary findings of the survey, reported in Happell, Scott, and Platania-Phung (2013), found that nurses were generally in favor of the notion of a CHN; however, they held some concerns, such as the risk of role fragmentation and de-skilling. There was a lack of consistency in responses in favor of or not supporting this role, raising the question of what factors (e.g., views and perceptions) are associated with support for the CHN role. Given there are different levels of support for the CHN role, the aims and objectives of this paper were to identify whether nurse-based beliefs predict support for the CHN role, based 163
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
on self-administered survey data. We anticipated that nurse beliefs and views about the level of consumer health, how well it was being supported by healthcare services, and the role of nurses and the mental healthcare system in consumer physical health would have a bearing on level of support for the CHN, because the CHN is designed to address this set of problems with the healthcare system (lower cardiometabolic health, cardiometabolic health care gaps, need for nurse education in cardiovascular care, and other care integration strategies). Specifically, it was hypothesized that CHN role support would be differentiated by each of the following beliefs or views: (a) inadequate treatment by general practitioners (GPs) of consumers’ physical health needs, (b) a perception of relative poorer health of consumers compared to the general population, (c) identified need for training in cardiovascular and diabetes care, (d) perceived value of physical health care strategies, and (e) the view that mental health services have an obligation to provide physical health care. Method Participants Nurses in the mental health sector were sourced from the membership pool of the Australian College of Mental Health Nurses (ACMHN). The ACMHN is the only national organization representing the interests of nurses who care for people with mental illness, and the sole credentialing body. Given this, the ACMHN was considered as the best access point to obtain a representative sample of nurses in mental health services. It was estimated in 2011 that 20,000 nurses were working in mental health services (Australian Institute of Health and Welfare, 2013). Determination of sample size was based on Cohen’s (1992) criteria. Based on these calculations, to have the capacity to detect small effects (such as 0.1), for a regression comprised of five independent variables, and an α of .05, Cohen (1992, p. 158) indicates a minimum sample size of 645. The current sample was just below this (n = 643). For the final sample of 634 participants, 72.7% were female (n = 468). In terms of sample size, the most represented areas of Australia were consistent with population density, with eastern seaboard states the most salient: Victoria (n = 154, 23.9%), New South Wales (n = 175, 27.2%), and Queensland (n = 163, n = 25.3%). Community nurses made up almost half of the sample (48%, n = 309), and inpatient nurses, 22% (n = 142). The remaining 41.1% (n = 265) were nurses in other mental healthcare settings, such as primary care, emergency departments, and prisons. Although this was a nonrandom sample, nurses employed in the public sector made up a significant proportion of it (70.3%, n = 453), consistent with the broader population of 164
nurses in the mental health sector (Australian Institute of Health and Welfare, 2011). Measures Questions for variables in the current analysis were drawn from an array of sections of the full electronic survey. The question areas that were pertinent to the present paper are presented in the same order as they appeared in the survey. Apart from the questions on physical healthcare training needs, all measures reported in this paper were developed by the researchers for the current research. Perceived Relative Health. Participants are asked: “How would you rate the physical health of consumers of MH services, compared to members of the wider community.” This specifically refers to the following health problems: cardiovascular disease, diabetes, obesity, respiratory conditions, oral/ dental conditions. The response options ranged from 1 (much worse) to 5 (much better). The Cronbach’s alpha (internal) reliability for these items was .84. Therefore, the shorthand for this variable will be “Relative health.” Views on Healthcare Arrangements. A list of statements on various features of physical health in a mental health setting was presented, and participants were asked to respond with their level of agreement with each statement on a Likert scale from 1 (strongly disagree) to 5 (strongly agree). Out of the range of views, two were selected on the basis of their anticipated contribution to shaping nurses’ views about the CHN role: (a) perceived GP neglect—“GPs neglect the physical health of consumers with serious mental illness” and (b) view on mental health service obligations—“The mental health care system has an obligation to improve the physical health of consumers with mental illness.” These two were chosen out of the broader pool of 18 statements, as they take the stance that there are gaps in primary care—gaps that may lead to the view that a CHN would be desirable. Therefore, the shorthand for these variables will be “GP neglect physical health” and “MH system obligation,” respectively. Value of Physical Healthcare Initiatives. On perceived value of public health strategies, participants were asked: “For each of the strategies listed below, please rate their potential for contributing to improving the physical health of consumers.” Ten strategies were listed. Examples of general initiatives include “general health bus,” “smoking cessation program,” and “mental illness stigma reduction program for primary care staff.” The Likert-type rating scale ranged from 1 “Negative value/counter-productive” to 5 “Significant value.” Two items in the list of initiatives were similar to the proposal for a CHN role, and so were not included in the scoring in order to avoid redundancy in the regression model. The two items excluded Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
were (a) “Full-time nurse specializing in physical health care, to support mental health care team (a ‘go to person’ for everything on physical illness)” and (b) “Workplace training of nurses on physical care tasks and responsibilities.” Internal reliability was .74. Therefore, the shorthand for this variable will be “Initiative value.” Support of CHN. The section on the CHN began with a description of the role, and read as follows: The Cardiometabolic Health Nurse (CHN) is a proposed specialist role. The CHN is a nurse with expertise in cardiometabolic health (e.g., cardiovascular disease and diabetes) assessment and treatment. A CHN would take on primary responsibility for the cardiometabolic health care of consumers in a mental health service, including tasks such as blood tests, referrals to GP’s and specialists, monitoring of overweight/obesity, and providing lifestyle advice. Mental health nurses would still be involved with the primary care of consumers, but would have the option of referring a consumer to the CHN for screening and monitoring of cardiometabolic health issues. Participants were asked to “choose the response that most accurately describes your views of the CHN role in relation to the following statements” using a Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). The 14 items covered the following issues: physical health improvements from CHN treatment, workplace suitability, capacity to reduce nurse colleague workloads, responsiveness of consumers, capacity for prevention of metabolic disorder, costs relative to benefits, increases in screening and assessment, and risks of de-skilling and fragmentation. In terms of number of “positive” and “negative” statements, there was around even attention each in the section. The current analysis was concerned not with specific views on the CHN role, but on general favor or non-favor. All intercorrelations between items were statistically significant (ps < .05). Before combining scores to have a single variable on CHN support, the set of items was explored for unidimensionality based on the scree plot and principal component analysis. The scree plot suggested one or two components. Inspection of the two-dimensional component plot (using oblique rotation) suggested that the second component reflected statements against the role, and so did not represent a substantive additional variable. Therefore, only the first dimension was considered and interpreted as a summary of the overall support or otherwise for the CHN role. Component loadings ranged from .35 to .81. All items were summed, where ratings for “negative” statements were reverse scored so that a higher overall score would represent higher support for the CHN role. Internal reliability was .87. Therefore, the shorthand for this outcome variable will be “Support of CHN role.” Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
Physical Healthcare Training Needs Nurses perceived physical healthcare training as necessary using items adapted from the Physical Health Attitude Scale for Mental Health Nurses (Robson & Haddad, 2012). The prompt was “I would like more training on.” The answer format was yes, no, not sure. The current analysis focused only on training areas directly related to cardiometabolic health. The two training need items—interest in training in cardiovascular disease care and in diabetes care—were dichotomized so that participants who wanted training in both were in one group (n = 439, 68.3%), while participants who would not like training in either one or the other or both were categorized as a second group (n = 204, 31.7%). Therefore, the shorthand for this variable will be “Want training CVD.”
Pilot Study of Survey As most of the survey included new questions, the full survey was piloted with 15 people with a professional background in public health and nursing. There were no significant issues with the design of the survey found from the pilot data, although refinements to presentation and wording of some questions were undertaken.
Procedure To support the current research while ensuring anonymity of survey participants, ACMHN staff delivered an invitation e-mail to the full membership list. The invitation for participation included a brief background to the topic. A more detailed introductory sheet was sent as an attachment. This informed ACMHN members that participation was voluntary and that neither the researchers nor the ACMHN would be able to identify who participated or who did not. Consent to participate was expressed through entering the survey. A hyperlink to the survey was included in the invitation. The survey was active online from May to July 2012. Follow-up e-mails to the membership body by ACMHN administration took place to increase the response rate. The final response rate was 22.2% (643 responses to around 2,852 invitations).
Data Analysis The distributional attributes of the variables were examined and a square root transformation was made to the dependent variable (support of CHN role) to reduce skewness. The association of key variables with support of the CHN role was determined using multiple linear regression. Analyses were conducted in SPSS V.20 (IBM, Chicago, IL, USA). 165
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
GP neglect MH system obligation Perceived relative health Initiative value Support of CHN role
Range
M (SD)
Skewness
Kurtosis
1–5 1–5 5–25 12–35 20–70 0–6.14a
3.10 4.37 7.81 31.03 51.43 2.84
−.08/.10 −1.72/.10 1.03/.10 −1.35/.10 −.52/.10 0.29/.10a
−.48/.19 4.00/.19 2.70/.19 3.13/.19 .45/.19 .36/.19a
(0.98) (0.80) (2.53) (3.42) (8.84) (1.05)a
Table 1. Descriptives for Variables in the Regression Model (N = 643)
Note. aTransformed variable. Need for cardiometabolic healthcare training not included as it was a dichotomous variable. CHN, cardiometabolic health nurse; GP, general practitioner; MH, mental health.
support. The view that GPs neglect consumer physical health was associated with higher CHN support (t = 3.07, p < .05). In addition, the view that mental health services have an obligation to increase physical health of people with SMI also showed a statistically significant and positive association with CHN support (t = 2.00, p < .05). An indication of perceived need for training in physical health care (both cardiovascular and diabetes vs. wanting one or the other area or neither) also significantly predicted CHN support (t = 3.69, p < .05); those wanting both cardiovascular and diabetes training expressed higher support for the CHN role. The model accounted for around 15% of variance in CHN support (adjusted R2 = .148). See Table 3.
Results Descriptives Descriptive information for variables entered into the regression was presented in Table 1. The mean level of support of the CHN role was 51.43, indicating that, in general, participants were slightly in favor of the role. Table 2 presents the intercorrelations between the variables, and shows that the magnitude of coefficients was small or moderate. The largest correlation was between initiative value and support for CHN (r = .33, p < .01). Before running an overall regression, checks were undertaken for differences in CHN support based on whether nurses were in inpatient, community, or other settings. Inspection of boxplots and F ratios from analysis of variance did not indicate any differences in CHN support based on nurse setting.
Discussion To our knowledge, this is a landmark study on predictors of nurses’ views on introduction of the CHN role in mental health settings as a way to improve the cardiometabolic health of people with SMI. There is little research on views on nurse roles for physical health care (Howard & Gamble, 2011; Wright et al., 2006). Views about changes in nurse roles (e.g., introduction of a specialist nurse such as the CHN) will influence the success or otherwise in implementing these roles, meaning the current research is very timely. Previous research suggests nurse-based physical health care in mental health settings is clinically effective (Osborn, Nazareth, Wright, & King, 2010; Prebble et al., 2011). Due to limited research the potential cost-effectiveness is unknown, although research into the cost of metabolic monitoring and treatment is less costly than treatment as usual (Druss, von
Regression Analysis There were no missing data for the current analyses. Plots of the residuals for the regression did not indicate divergence from normality. The overall regression model significantly predicted CHN support, F(5, 637) = 23.24, p < .001. Table 2 presents the standardized and nonstandardized coefficients of predictor variables for CHN role support. Perceived relative health did not significantly predict CHN support (t = −.82, p > .05), although the valence of the coefficient was in the direction anticipated, where perceived relative ill health of consumers with SMI was associated with higher CHN
Variable GP neglect physical health MH system obligation Relative health Initiative value Want training CVD Support of CHN
1 2 3 4 5 6
1
2
3
4
5
6
1 .08* −.13* .03 .10*a .13**
1 .16** .23** .03a .15**
1 −.11** −.14**a −.10**
1 .21**a .33**
1 .23**a
1
Table 2. Intercorrelations Between Beliefs and Support for CHN
Note. Point-biserial correlation. *p < .05, **p < .01. CHN, cardiometabolic health nurse; CVD, cardiovascular disease; GP, general practitioner; MH, mental health. a
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Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
Table 3. Summary of Multiple Regression Model for Predicting Support of CHN Role (N = 643) Variable
B
SE B
ß
p
Relative health MH system obligation GP neglect physical health Initiative value Want training CVD
−.01 .10 .12 .08 .31
.02 .05 .04 .01 .08
−.82 .08 .11 .27 .14
ns * ** *** ***
Note. *p < .05, **p < .01, ***p < .001. CHN, cardiometabolic health nurse; CVD, cardiovascular disease; GP, general practitioner; MH, mental health; ns, not significant.
Esenwein, Compton, Zhao, & Leslie, 2011). Costeffectiveness is an important consideration and further research is required to consider the financial implications of the role. The findings support the idea that a CHN role could represent a critical step in building a more central role of nurses in reducing healthcare inequalities. The view that the physical health of consumers with SMI is neglected by GPs was related to support for the CHN role, suggesting, as was anticipated, that it is the perceived gap in care that may influence support for the CHN. Nurse views that GPs may not give sufficient attention to physical health problems have previously been identified (Happell, Scott, et al., 2012), and the current results suggest this opinion is widespread. It is important to note that irrespective of views on GPs, belief in obligations of mental health services to provide physical health care was a significant predictor of CHN role support, suggesting the current participants want to see physical healthcare provision in both primary care and mental health services (i.e., provided comprehensively rather than in one setting). At the same time, it could be the case that perceptions of adequate attention from primary care services and views that mental health services do not have an obligation to contribute to physical health care are barriers to implementation of the CHN role. Therefore, nurse support for a CHN role may be enhanced by clarity in mental health service policy on obligations with respect to the physical health of consumers with SMI (e.g., Ministerial Advisory Committee on Mental Health, 2011). It was found that nurses who indicated a need for training to improve the cardiometabolic care for people with SMI tended to also support the CHN role, and this relationship was statistically significant. This suggests that nurses do not see the introduction of a CHN as a risk in terms of fragmentation or de-skilling—a common concern about the institutionalization of nurse specialization (e.g., Happell, Scott, et al., 2013; Robson, Haddad, Gray, & Gournay, 2012; Wright et al., 2006). Indeed, the proposed CHN role is not intended to be an alternative, but rather a complement to generalist skills and competencies of all nurses in the mental health sector (Australian Institute of Health and Welfare, 2013). Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
National training of mental health nursing in the domain of primary care, such as diabetes care, is a focus in countries such as the United Kingdom (Bradshaw & Pedley, 2012; Robson et al., 2012), but in Australia, while comprehensive training of all nurses is highly desirable, there is little to suggest such change is occurring, and the increased ill health of consumers with SMI remains unaddressed (Happell et al., 2011). Alongside workforce training and other physical health initiatives such as public awareness campaigns (Ahire, Sheridan, Regbetz, Stacey, & Scott, 2013), the CHN may be effective in addressing the inequalities in cardiometabolic care of people with SMI in both the short and long terms. The positive prediction of CHN support by training needs suggests that a CHN may be a preferred source of workplace learning for other nurses involved in the care of people with a mental illness. There is limited research on training needs and preferences of mental health nurses regarding the physical health care of people with SMI (Hardy, White, Deane, & Gray, 2011; Howard & Gamble, 2011; Nash, 2005). Future studies of training needs of currently practicing nurses should incorporate the CHN as an option for receiving guidance and training on the cardiometabolic health care of people with SMI. Furthermore, the development of a specialized postgraduate training program for the CHN is worthy of consideration. The strongest predictor of CHN support was the perceived value of initiatives for improving physical health of people with SMI that were separate from the idea of a CHN (e.g., colocation of primary and mental health services, stigma reduction in primary care staff). One interpretation of this finding is that nurses see the CHN as an important component of a larger suite of approaches to increasing the physical health of consumers with SMI. Further research could seek to identify nurses’ views on the value of a range of physical or cardiometabolic healthcare initiatives for people with SMI and what they consider to be the optimal ways to reduce inequalities in physical health care. This would clarify how nurses see CHN “fits” with a broader repertoire of changes to health care. It was predicted that nurses’ views on the relative physical health of consumers compared to the wider community would be associated with higher support for the CHN role, and this was not found. A possible reason is that this measure took into account a number of different physical health problems such as dental and respiratory conditions, in addition to direct cardiometabolic health issues. Furthermore, this result may suggest that nurse views on introduction of the CHN are more based on their views on how well services are meeting (or not) needs, rather than the level of need per se, and the former were better captured by the other independent variables. Although this study has established that there are multiple nurse perceptions and views that impinge on support of the 167
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
CHN role, it should be noted that these domains addressed only 15% of variance in CHN support. This finding indicates that there is much more research required to identify other contributing factors to support for CHN roles. Potential factors worthy of investigation include work hours, beliefs about specialist roles in general, and perceived efficacy of cardiometabolic health care. In addition, our survey was on self-reported beliefs and views; other types of measurement of nurse and organizational factors may better “address” variance in CHN support. This study has a number of limitations. Firstly, typical of electronically administered surveys, the response rate for this study was low (22.2%). Given this, the researchers are very cautious on the level of generalizability of the current findings. Secondly, some variables (e.g., on perceived GP neglect) were single-item questions, and therefore reliability could not be determined. Finally, the sample was nonrandom and likely to include people more concerned about physical ill health of consumers. It is not clear though if this would impinge on views on the CHN role as perceived relative health of consumers had no bearing on CHN role support. The current findings indicate that further research is needed on nurses’ views of the CHN and factors that may determine support of the new role. A qualitative analysis of nurses’ views on the CHN role using telephone interviews, focus groups, or analysis of open-ended survey questions will aid in identifying additional factors that were not addressed in the current analysis of our survey. Further research is needed in which nurses and other stakeholder views on the feasibility and potential clinical efficacy of CHN roles can be investigated. Finally, future research should include clinical trials incorporating the CHN into mental health services to determine the effectiveness of the role in improving the cardiometabolic outcomes and physical health care of people with SMI, and to examine its acceptability for other mental health professionals when working alongside the CHN in the clinical setting. The CHN represents an integrated care approach to improving the cardiometabolic health of people with SMI (Australian Institute of Health and Welfare, 2013). Readiness and endorsement of the CHN role may contribute to its future adoption and clinical effectiveness; however, there is very little knowledge on the correlates of nurse (dis)favoring of the CHN. The current research identified a number of nurse perspectives as predictors of higher support for the CHN, namely nurse views on the presence of gaps in primary care and obligation of mental health services to provide comprehensive care, perceived effectiveness of general public health strategies at improving physical health care, and want for training on cardiovascular health and diabetes. While focusing on these beliefs may enhance support for the CHN role, the main factors underlying systematic differences in CHN views, including those that may be associated with lower support for 168
the role, remain unknown. Nevertheless, from what has been gleaned from the current research, it would be worthwhile to see whether developing a culture that is orientated to cardiometabolic healthcare needs of consumers with SMI— such as nurse interest in cardiometabolic healthcare training and enhanced awareness of primary health care gaps—would increase nurse support for the CHN role. Acknowledgments The authors would like to thank the mental health nurses for their time and valuable input. Furthermore, the authors would like to acknowledge the Australian College of Mental Health Nurses, particularly Kim Ryan and Haylie Maylia, for their invaluable assistance in distributing the survey. Funding Research Advancement Award Scheme and Merit Grant Scheme of Central Queensland University provided the funding to make this work possible. References Ahire, M., Sheridan, J., Regbetz, S., Stacey, P., & Scott, J. G. (2013). Back to basics: Informing the public of co-morbid physical health problems in those with mental illness. Australian and New Zealand Journal of Psychiatry, 47(2), 177–184. doi:10.1177/0004867412450753 Australian Institute of Health and Welfare. (2011). Nursing and midwifery labour force 2009. Canberra: Author. Australian Institute of Health and Welfare. (2013). Mental health services: In brief 2013. Canberra: Author. 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 Bradshaw, T., & Pedley, R. (2012). Evolving role of mental health nurses in the physical health care of people with serious mental health illness. International Journal of Mental Health Nursing, 21(3), 266–273. doi:10.1111/j.1447-0349.2012.00818.x Bressington, D. T., Mui, J., Cheung, E. F., Petch, J., Clark, A. B., & Gray, R. (2013). The prevalence of metabolic syndrome amongst patients with severe mental illness in the community in Hong Kong—a cross sectional study. BMC Psychiatry, 13, 87. doi:10.1186/1471-244X-13-87 Brunero, S., & Lamont, S. (2009). Systematic screening for metabolic syndrome in consumers with severe mental illness. International Journal of Mental Health Nursing, 18, 144–150. doi:10.1111/j.1447-0349.2009.00595.x Coghlan, R., Lawrence, D., Holman, C. D. J., & Jablensky, A. V. (2001). Duty to care: Physical illness in people with mental illness. Perth: University of Western Australia.
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Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
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Perspectives in Psychiatric Care
ISSN 0031-5990
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd, MEd, PhD, Chris Platania-Phung, BA (Hons), David Scott, BHM (Hons), PhD, and Robert Stanton, BHM (Hons), PhD Candidate Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd, MEd, PhD, is an Engaged Research Chair in Mental Health Nursing, Director, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Chris Platania-Phung, BA (Hons), is a Research Fellow, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; David Scott, BHM (Hons), PhD, is a Post-Doctoral Research Fellow, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; and Robert Stanton, BHM (Hons), PhD Candidate, is a Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia
Search terms: Cardiometabolic health nurse, cardiovascular disease, diabetes care, mental health care, serious mental 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 January 7, 2014; Final Revision received April 22, 2014; Accepted for publication May 29, 2014
PURPOSE: A cardiometabolic specialist nursing role could potentially improve physical health of people with serious mental illness. DESIGN AND METHODS: A national survey of Australian nurses working in mental health settings investigated predictors of support for the role. FINDINGS: Predictors included belief in physical healthcare neglect, interest in training; higher perceived value of improving physical health care. PRACTICE IMPLICATIONS: The findings suggest that nurses see the cardiometabolic health nurse role as a promising initiative for closing gaps in cardiometabolic health care and skilling other nurses in mental health. However, as the majority of variance in cardiometabolic health nurse support was unexplained, more research is urgently needed on factors that explain differences in cardiometabolic health nurse endorsement.
doi: 10.1111/ppc.12077
Recent evidence shows the prevalence of cardiovascular disease, diabetes, and metabolic syndrome is higher for people diagnosed with serious mental illness (SMI) (Bressington et al., 2013; Ohaeri & Akanji, 2011). As a result, people with SMI experience higher mortality risk compared to the general population (De Hert, Schreurs, Vancampfort, & van Winkel, 2009; De Hert et al., 2011). Given the higher prevalence of cardiometabolic disease and higher mortality risk in people with SMI such as schizophrenia and bipolar disorder, people with SMI can benefit greatly from prevention and management strategies such as cardiometabolic screening and referral to primary care services, close attention to drug treatments, and support of health-behavior change (Meyer & Stahl, 2009). However, much improve162
ment to the current level of access to high-standard cardiometabolic and diabetes care services is needed. As inequalities in physical health care of people with SMI are systemic, multipronged strategies for better services are needed (Bradshaw & Pedley, 2012; Hardy & Thomas, 2012; Horvitz-Lennon, Kilbourne, & Pincus, 2006; Lawrence & Kisely, 2010; Meyer, Peteet, & Joseph, 2009; Sajatovic et al., 2011; Viron & Stern, 2010). To date, advances in reducing inequality in access to and quality of cardiometabolic care for people with SMI accessing mental health services are based on preliminary trials of new care models (Blythe & White, 2012; Faulkner, Soundy, & Lloyd, 2003; Happell, Davies, & Scott, 2012; van Hasselt, Krabbe, van Ittersum, Postma, & Loonen, 2013). Significant changes are still needed before there is Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
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progress in reversing the inadequate cardiometabolic health care for people with SMI (Happell, Scott, et al., 2012). One potential strategy to improve the poorer physical health care of people with SMI is the inclusion of a nurse who assumes responsibility of coordinating physical health care to maximize the provision of systematic and comprehensive care in terms of both prevention and management. Brunero and Lamont (2009) described a new role focused on screening for risks as a “cardiometabolic mental health nurse consultant” (p. 148). Similarly, Happell, Scott, and Platania-Phung (2013) proposed the “cardiometabolic health nurse” (CHN) to integrate primary care and mental health care, and most of all, to ensure this high-risk group have access to primary care services that they may not receive or be able to access outside of mental health services. Specifically, the role of the CHN is to serve the following functions: (a) prevent and manage cardiometabolic-related conditions; (b) be a “go to” person for advice on physical health for nurses and other mental healthcare staff; (c) incorporate routine cardiometabolic screening into routine care of consumers with SMI (e.g., blood tests) as a main option for referral by nurses; and (d) provide health and lifestyle education to consumers with SMI. The title of cardiovascular health nurse is evident in some care settings (e.g., Wexler et al., 2004), but not in relation to care for people with mental illness. Although the clinical outcomes of a CHN role as part of mental healthcare services have not been examined, research on service evaluation for trials that included nurses providing primary care directly has demonstrated significant increases in delivery of physical health care (Druss et al., 2010; Griswold et al., 2005; Ohlsen, Peacock, & Smith, 2005; Simonelli-Munoz et al., 2012). CHNs who foster full commitment to cardiometabolic health care in mental health services may be of benefit for mental health consumers in Australia (both inpatient and community), as, similar to other parts of the world, these consumers experience shortfalls in access and quality care in that region (Coghlan, Lawrence, Holman, & Jablensky, 2001; Happell, Scott, et al., 2012; Hyland, Judd, Davidson, Jolley, & Hocking, 2003). In Australia, primary care and mental health services are administered separately (Duckett, 2007). The complexity of health care in Australia is due to the involvement of federal, state, and local governments (Duckett, 2007). Mental health services are a part of general healthcare services for each healthcare district (Australian Institute of Health and Welfare, 2013). Mental health service provision is comprised of public, private, and nongovernment community outreach. Public health services are available at no cost, while private services are usually paid for through individual health insurance (Australian Institute of Health and Welfare, 2013). The complexity of the healthcare system and the separation of mental health from primary care contribute to Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
the challenges in providing quality physical health services to people with mental illness. Under the current system, the CHN would be employed by the mental health service in a salaried position. The viability of actual implementation of the CHN is likely to depend on the extent of support for the role by mental health nurses. Common issues raised in regard to the introduction of new nursing roles include fragmentation of existing roles, de-skilling, and financial costs (Peplau, 2003). In light of these concerns, it is important to clarify that the CHN is intended to complement existing service delivery and facilitate cardiometabolic health care of patients with SMI within mental healthcare teams. The role is not the only strategy designed to address health inequities in the area of physical health care. Furthermore, the role is not intended to compensate fully for deficits in the knowledge and skill of nurses to provide physical healthcare (Happell, Scott, et al., 2013) views on whether a CHN would improve clinical care are likely to vary. Wright, Osborn, Nazareth, and King (2006) explored the proposal of a similar role in the United Kingdom for healthcare staff in community services. Findings included a number of advantages such as increased screening, and disadvantages such as costs. Countries such as the United States have trialed integrated care models and demonstrated increases in cardiometabolic care and reduction of cardiovascular risks (Druss & von Esenwein, 2006; Druss, Rohrbaugh, Levinson, & Rosenheck, 2001). Nurses have been instrumental to these approaches (e.g., Druss et al., 2010). Due to differences in mental healthcare delivery across countries, the generalizability of the findings of the Wright et al.’s (2006) study and integrated care models in the United States is limited, and so further research is required on how the CHN might be supported in Australia. In addition, a quantitative study with the purpose of identifying precursors to support for the role of the CHN would inform policy makers in understanding the reasons for support for the CHN role and the subsequent need for mental healthcare reform. To address this literature gap, we conducted a national survey on the views of nurses working in the mental health sector of Australia on the state of physical healthcare services and the role of nurses in improving services for people with SMI. Preliminary findings of the survey, reported in Happell, Scott, and Platania-Phung (2013), found that nurses were generally in favor of the notion of a CHN; however, they held some concerns, such as the risk of role fragmentation and de-skilling. There was a lack of consistency in responses in favor of or not supporting this role, raising the question of what factors (e.g., views and perceptions) are associated with support for the CHN role. Given there are different levels of support for the CHN role, the aims and objectives of this paper were to identify whether nurse-based beliefs predict support for the CHN role, based 163
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
on self-administered survey data. We anticipated that nurse beliefs and views about the level of consumer health, how well it was being supported by healthcare services, and the role of nurses and the mental healthcare system in consumer physical health would have a bearing on level of support for the CHN, because the CHN is designed to address this set of problems with the healthcare system (lower cardiometabolic health, cardiometabolic health care gaps, need for nurse education in cardiovascular care, and other care integration strategies). Specifically, it was hypothesized that CHN role support would be differentiated by each of the following beliefs or views: (a) inadequate treatment by general practitioners (GPs) of consumers’ physical health needs, (b) a perception of relative poorer health of consumers compared to the general population, (c) identified need for training in cardiovascular and diabetes care, (d) perceived value of physical health care strategies, and (e) the view that mental health services have an obligation to provide physical health care. Method Participants Nurses in the mental health sector were sourced from the membership pool of the Australian College of Mental Health Nurses (ACMHN). The ACMHN is the only national organization representing the interests of nurses who care for people with mental illness, and the sole credentialing body. Given this, the ACMHN was considered as the best access point to obtain a representative sample of nurses in mental health services. It was estimated in 2011 that 20,000 nurses were working in mental health services (Australian Institute of Health and Welfare, 2013). Determination of sample size was based on Cohen’s (1992) criteria. Based on these calculations, to have the capacity to detect small effects (such as 0.1), for a regression comprised of five independent variables, and an α of .05, Cohen (1992, p. 158) indicates a minimum sample size of 645. The current sample was just below this (n = 643). For the final sample of 634 participants, 72.7% were female (n = 468). In terms of sample size, the most represented areas of Australia were consistent with population density, with eastern seaboard states the most salient: Victoria (n = 154, 23.9%), New South Wales (n = 175, 27.2%), and Queensland (n = 163, n = 25.3%). Community nurses made up almost half of the sample (48%, n = 309), and inpatient nurses, 22% (n = 142). The remaining 41.1% (n = 265) were nurses in other mental healthcare settings, such as primary care, emergency departments, and prisons. Although this was a nonrandom sample, nurses employed in the public sector made up a significant proportion of it (70.3%, n = 453), consistent with the broader population of 164
nurses in the mental health sector (Australian Institute of Health and Welfare, 2011). Measures Questions for variables in the current analysis were drawn from an array of sections of the full electronic survey. The question areas that were pertinent to the present paper are presented in the same order as they appeared in the survey. Apart from the questions on physical healthcare training needs, all measures reported in this paper were developed by the researchers for the current research. Perceived Relative Health. Participants are asked: “How would you rate the physical health of consumers of MH services, compared to members of the wider community.” This specifically refers to the following health problems: cardiovascular disease, diabetes, obesity, respiratory conditions, oral/ dental conditions. The response options ranged from 1 (much worse) to 5 (much better). The Cronbach’s alpha (internal) reliability for these items was .84. Therefore, the shorthand for this variable will be “Relative health.” Views on Healthcare Arrangements. A list of statements on various features of physical health in a mental health setting was presented, and participants were asked to respond with their level of agreement with each statement on a Likert scale from 1 (strongly disagree) to 5 (strongly agree). Out of the range of views, two were selected on the basis of their anticipated contribution to shaping nurses’ views about the CHN role: (a) perceived GP neglect—“GPs neglect the physical health of consumers with serious mental illness” and (b) view on mental health service obligations—“The mental health care system has an obligation to improve the physical health of consumers with mental illness.” These two were chosen out of the broader pool of 18 statements, as they take the stance that there are gaps in primary care—gaps that may lead to the view that a CHN would be desirable. Therefore, the shorthand for these variables will be “GP neglect physical health” and “MH system obligation,” respectively. Value of Physical Healthcare Initiatives. On perceived value of public health strategies, participants were asked: “For each of the strategies listed below, please rate their potential for contributing to improving the physical health of consumers.” Ten strategies were listed. Examples of general initiatives include “general health bus,” “smoking cessation program,” and “mental illness stigma reduction program for primary care staff.” The Likert-type rating scale ranged from 1 “Negative value/counter-productive” to 5 “Significant value.” Two items in the list of initiatives were similar to the proposal for a CHN role, and so were not included in the scoring in order to avoid redundancy in the regression model. The two items excluded Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
were (a) “Full-time nurse specializing in physical health care, to support mental health care team (a ‘go to person’ for everything on physical illness)” and (b) “Workplace training of nurses on physical care tasks and responsibilities.” Internal reliability was .74. Therefore, the shorthand for this variable will be “Initiative value.” Support of CHN. The section on the CHN began with a description of the role, and read as follows: The Cardiometabolic Health Nurse (CHN) is a proposed specialist role. The CHN is a nurse with expertise in cardiometabolic health (e.g., cardiovascular disease and diabetes) assessment and treatment. A CHN would take on primary responsibility for the cardiometabolic health care of consumers in a mental health service, including tasks such as blood tests, referrals to GP’s and specialists, monitoring of overweight/obesity, and providing lifestyle advice. Mental health nurses would still be involved with the primary care of consumers, but would have the option of referring a consumer to the CHN for screening and monitoring of cardiometabolic health issues. Participants were asked to “choose the response that most accurately describes your views of the CHN role in relation to the following statements” using a Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). The 14 items covered the following issues: physical health improvements from CHN treatment, workplace suitability, capacity to reduce nurse colleague workloads, responsiveness of consumers, capacity for prevention of metabolic disorder, costs relative to benefits, increases in screening and assessment, and risks of de-skilling and fragmentation. In terms of number of “positive” and “negative” statements, there was around even attention each in the section. The current analysis was concerned not with specific views on the CHN role, but on general favor or non-favor. All intercorrelations between items were statistically significant (ps < .05). Before combining scores to have a single variable on CHN support, the set of items was explored for unidimensionality based on the scree plot and principal component analysis. The scree plot suggested one or two components. Inspection of the two-dimensional component plot (using oblique rotation) suggested that the second component reflected statements against the role, and so did not represent a substantive additional variable. Therefore, only the first dimension was considered and interpreted as a summary of the overall support or otherwise for the CHN role. Component loadings ranged from .35 to .81. All items were summed, where ratings for “negative” statements were reverse scored so that a higher overall score would represent higher support for the CHN role. Internal reliability was .87. Therefore, the shorthand for this outcome variable will be “Support of CHN role.” Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
Physical Healthcare Training Needs Nurses perceived physical healthcare training as necessary using items adapted from the Physical Health Attitude Scale for Mental Health Nurses (Robson & Haddad, 2012). The prompt was “I would like more training on.” The answer format was yes, no, not sure. The current analysis focused only on training areas directly related to cardiometabolic health. The two training need items—interest in training in cardiovascular disease care and in diabetes care—were dichotomized so that participants who wanted training in both were in one group (n = 439, 68.3%), while participants who would not like training in either one or the other or both were categorized as a second group (n = 204, 31.7%). Therefore, the shorthand for this variable will be “Want training CVD.”
Pilot Study of Survey As most of the survey included new questions, the full survey was piloted with 15 people with a professional background in public health and nursing. There were no significant issues with the design of the survey found from the pilot data, although refinements to presentation and wording of some questions were undertaken.
Procedure To support the current research while ensuring anonymity of survey participants, ACMHN staff delivered an invitation e-mail to the full membership list. The invitation for participation included a brief background to the topic. A more detailed introductory sheet was sent as an attachment. This informed ACMHN members that participation was voluntary and that neither the researchers nor the ACMHN would be able to identify who participated or who did not. Consent to participate was expressed through entering the survey. A hyperlink to the survey was included in the invitation. The survey was active online from May to July 2012. Follow-up e-mails to the membership body by ACMHN administration took place to increase the response rate. The final response rate was 22.2% (643 responses to around 2,852 invitations).
Data Analysis The distributional attributes of the variables were examined and a square root transformation was made to the dependent variable (support of CHN role) to reduce skewness. The association of key variables with support of the CHN role was determined using multiple linear regression. Analyses were conducted in SPSS V.20 (IBM, Chicago, IL, USA). 165
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
GP neglect MH system obligation Perceived relative health Initiative value Support of CHN role
Range
M (SD)
Skewness
Kurtosis
1–5 1–5 5–25 12–35 20–70 0–6.14a
3.10 4.37 7.81 31.03 51.43 2.84
−.08/.10 −1.72/.10 1.03/.10 −1.35/.10 −.52/.10 0.29/.10a
−.48/.19 4.00/.19 2.70/.19 3.13/.19 .45/.19 .36/.19a
(0.98) (0.80) (2.53) (3.42) (8.84) (1.05)a
Table 1. Descriptives for Variables in the Regression Model (N = 643)
Note. aTransformed variable. Need for cardiometabolic healthcare training not included as it was a dichotomous variable. CHN, cardiometabolic health nurse; GP, general practitioner; MH, mental health.
support. The view that GPs neglect consumer physical health was associated with higher CHN support (t = 3.07, p < .05). In addition, the view that mental health services have an obligation to increase physical health of people with SMI also showed a statistically significant and positive association with CHN support (t = 2.00, p < .05). An indication of perceived need for training in physical health care (both cardiovascular and diabetes vs. wanting one or the other area or neither) also significantly predicted CHN support (t = 3.69, p < .05); those wanting both cardiovascular and diabetes training expressed higher support for the CHN role. The model accounted for around 15% of variance in CHN support (adjusted R2 = .148). See Table 3.
Results Descriptives Descriptive information for variables entered into the regression was presented in Table 1. The mean level of support of the CHN role was 51.43, indicating that, in general, participants were slightly in favor of the role. Table 2 presents the intercorrelations between the variables, and shows that the magnitude of coefficients was small or moderate. The largest correlation was between initiative value and support for CHN (r = .33, p < .01). Before running an overall regression, checks were undertaken for differences in CHN support based on whether nurses were in inpatient, community, or other settings. Inspection of boxplots and F ratios from analysis of variance did not indicate any differences in CHN support based on nurse setting.
Discussion To our knowledge, this is a landmark study on predictors of nurses’ views on introduction of the CHN role in mental health settings as a way to improve the cardiometabolic health of people with SMI. There is little research on views on nurse roles for physical health care (Howard & Gamble, 2011; Wright et al., 2006). Views about changes in nurse roles (e.g., introduction of a specialist nurse such as the CHN) will influence the success or otherwise in implementing these roles, meaning the current research is very timely. Previous research suggests nurse-based physical health care in mental health settings is clinically effective (Osborn, Nazareth, Wright, & King, 2010; Prebble et al., 2011). Due to limited research the potential cost-effectiveness is unknown, although research into the cost of metabolic monitoring and treatment is less costly than treatment as usual (Druss, von
Regression Analysis There were no missing data for the current analyses. Plots of the residuals for the regression did not indicate divergence from normality. The overall regression model significantly predicted CHN support, F(5, 637) = 23.24, p < .001. Table 2 presents the standardized and nonstandardized coefficients of predictor variables for CHN role support. Perceived relative health did not significantly predict CHN support (t = −.82, p > .05), although the valence of the coefficient was in the direction anticipated, where perceived relative ill health of consumers with SMI was associated with higher CHN
Variable GP neglect physical health MH system obligation Relative health Initiative value Want training CVD Support of CHN
1 2 3 4 5 6
1
2
3
4
5
6
1 .08* −.13* .03 .10*a .13**
1 .16** .23** .03a .15**
1 −.11** −.14**a −.10**
1 .21**a .33**
1 .23**a
1
Table 2. Intercorrelations Between Beliefs and Support for CHN
Note. Point-biserial correlation. *p < .05, **p < .01. CHN, cardiometabolic health nurse; CVD, cardiovascular disease; GP, general practitioner; MH, mental health. a
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Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
Table 3. Summary of Multiple Regression Model for Predicting Support of CHN Role (N = 643) Variable
B
SE B
ß
p
Relative health MH system obligation GP neglect physical health Initiative value Want training CVD
−.01 .10 .12 .08 .31
.02 .05 .04 .01 .08
−.82 .08 .11 .27 .14
ns * ** *** ***
Note. *p < .05, **p < .01, ***p < .001. CHN, cardiometabolic health nurse; CVD, cardiovascular disease; GP, general practitioner; MH, mental health; ns, not significant.
Esenwein, Compton, Zhao, & Leslie, 2011). Costeffectiveness is an important consideration and further research is required to consider the financial implications of the role. The findings support the idea that a CHN role could represent a critical step in building a more central role of nurses in reducing healthcare inequalities. The view that the physical health of consumers with SMI is neglected by GPs was related to support for the CHN role, suggesting, as was anticipated, that it is the perceived gap in care that may influence support for the CHN. Nurse views that GPs may not give sufficient attention to physical health problems have previously been identified (Happell, Scott, et al., 2012), and the current results suggest this opinion is widespread. It is important to note that irrespective of views on GPs, belief in obligations of mental health services to provide physical health care was a significant predictor of CHN role support, suggesting the current participants want to see physical healthcare provision in both primary care and mental health services (i.e., provided comprehensively rather than in one setting). At the same time, it could be the case that perceptions of adequate attention from primary care services and views that mental health services do not have an obligation to contribute to physical health care are barriers to implementation of the CHN role. Therefore, nurse support for a CHN role may be enhanced by clarity in mental health service policy on obligations with respect to the physical health of consumers with SMI (e.g., Ministerial Advisory Committee on Mental Health, 2011). It was found that nurses who indicated a need for training to improve the cardiometabolic care for people with SMI tended to also support the CHN role, and this relationship was statistically significant. This suggests that nurses do not see the introduction of a CHN as a risk in terms of fragmentation or de-skilling—a common concern about the institutionalization of nurse specialization (e.g., Happell, Scott, et al., 2013; Robson, Haddad, Gray, & Gournay, 2012; Wright et al., 2006). Indeed, the proposed CHN role is not intended to be an alternative, but rather a complement to generalist skills and competencies of all nurses in the mental health sector (Australian Institute of Health and Welfare, 2013). Perspectives in Psychiatric Care 51 (2015) 162–170 © 2014 Wiley Periodicals, Inc.
National training of mental health nursing in the domain of primary care, such as diabetes care, is a focus in countries such as the United Kingdom (Bradshaw & Pedley, 2012; Robson et al., 2012), but in Australia, while comprehensive training of all nurses is highly desirable, there is little to suggest such change is occurring, and the increased ill health of consumers with SMI remains unaddressed (Happell et al., 2011). Alongside workforce training and other physical health initiatives such as public awareness campaigns (Ahire, Sheridan, Regbetz, Stacey, & Scott, 2013), the CHN may be effective in addressing the inequalities in cardiometabolic care of people with SMI in both the short and long terms. The positive prediction of CHN support by training needs suggests that a CHN may be a preferred source of workplace learning for other nurses involved in the care of people with a mental illness. There is limited research on training needs and preferences of mental health nurses regarding the physical health care of people with SMI (Hardy, White, Deane, & Gray, 2011; Howard & Gamble, 2011; Nash, 2005). Future studies of training needs of currently practicing nurses should incorporate the CHN as an option for receiving guidance and training on the cardiometabolic health care of people with SMI. Furthermore, the development of a specialized postgraduate training program for the CHN is worthy of consideration. The strongest predictor of CHN support was the perceived value of initiatives for improving physical health of people with SMI that were separate from the idea of a CHN (e.g., colocation of primary and mental health services, stigma reduction in primary care staff). One interpretation of this finding is that nurses see the CHN as an important component of a larger suite of approaches to increasing the physical health of consumers with SMI. Further research could seek to identify nurses’ views on the value of a range of physical or cardiometabolic healthcare initiatives for people with SMI and what they consider to be the optimal ways to reduce inequalities in physical health care. This would clarify how nurses see CHN “fits” with a broader repertoire of changes to health care. It was predicted that nurses’ views on the relative physical health of consumers compared to the wider community would be associated with higher support for the CHN role, and this was not found. A possible reason is that this measure took into account a number of different physical health problems such as dental and respiratory conditions, in addition to direct cardiometabolic health issues. Furthermore, this result may suggest that nurse views on introduction of the CHN are more based on their views on how well services are meeting (or not) needs, rather than the level of need per se, and the former were better captured by the other independent variables. Although this study has established that there are multiple nurse perceptions and views that impinge on support of the 167
Predictors of Nurse Support for the Introduction of the Cardiometabolic Health Nurse in the Australian Mental Health Sector
CHN role, it should be noted that these domains addressed only 15% of variance in CHN support. This finding indicates that there is much more research required to identify other contributing factors to support for CHN roles. Potential factors worthy of investigation include work hours, beliefs about specialist roles in general, and perceived efficacy of cardiometabolic health care. In addition, our survey was on self-reported beliefs and views; other types of measurement of nurse and organizational factors may better “address” variance in CHN support. This study has a number of limitations. Firstly, typical of electronically administered surveys, the response rate for this study was low (22.2%). Given this, the researchers are very cautious on the level of generalizability of the current findings. Secondly, some variables (e.g., on perceived GP neglect) were single-item questions, and therefore reliability could not be determined. Finally, the sample was nonrandom and likely to include people more concerned about physical ill health of consumers. It is not clear though if this would impinge on views on the CHN role as perceived relative health of consumers had no bearing on CHN role support. The current findings indicate that further research is needed on nurses’ views of the CHN and factors that may determine support of the new role. A qualitative analysis of nurses’ views on the CHN role using telephone interviews, focus groups, or analysis of open-ended survey questions will aid in identifying additional factors that were not addressed in the current analysis of our survey. Further research is needed in which nurses and other stakeholder views on the feasibility and potential clinical efficacy of CHN roles can be investigated. Finally, future research should include clinical trials incorporating the CHN into mental health services to determine the effectiveness of the role in improving the cardiometabolic outcomes and physical health care of people with SMI, and to examine its acceptability for other mental health professionals when working alongside the CHN in the clinical setting. The CHN represents an integrated care approach to improving the cardiometabolic health of people with SMI (Australian Institute of Health and Welfare, 2013). Readiness and endorsement of the CHN role may contribute to its future adoption and clinical effectiveness; however, there is very little knowledge on the correlates of nurse (dis)favoring of the CHN. The current research identified a number of nurse perspectives as predictors of higher support for the CHN, namely nurse views on the presence of gaps in primary care and obligation of mental health services to provide comprehensive care, perceived effectiveness of general public health strategies at improving physical health care, and want for training on cardiovascular health and diabetes. While focusing on these beliefs may enhance support for the CHN role, the main factors underlying systematic differences in CHN views, including those that may be associated with lower support for 168
the role, remain unknown. Nevertheless, from what has been gleaned from the current research, it would be worthwhile to see whether developing a culture that is orientated to cardiometabolic healthcare needs of consumers with SMI— such as nurse interest in cardiometabolic healthcare training and enhanced awareness of primary health care gaps—would increase nurse support for the CHN role. Acknowledgments The authors would like to thank the mental health nurses for their time and valuable input. Furthermore, the authors would like to acknowledge the Australian College of Mental Health Nurses, particularly Kim Ryan and Haylie Maylia, for their invaluable assistance in distributing the survey. Funding Research Advancement Award Scheme and Merit Grant Scheme of Central Queensland University provided the funding to make this work possible. References Ahire, M., Sheridan, J., Regbetz, S., Stacey, P., & Scott, J. G. (2013). Back to basics: Informing the public of co-morbid physical health problems in those with mental illness. Australian and New Zealand Journal of Psychiatry, 47(2), 177–184. doi:10.1177/0004867412450753 Australian Institute of Health and Welfare. (2011). Nursing and midwifery labour force 2009. Canberra: Author. Australian Institute of Health and Welfare. (2013). Mental health services: In brief 2013. Canberra: Author. 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 Bradshaw, T., & Pedley, R. (2012). Evolving role of mental health nurses in the physical health care of people with serious mental health illness. International Journal of Mental Health Nursing, 21(3), 266–273. doi:10.1111/j.1447-0349.2012.00818.x Bressington, D. T., Mui, J., Cheung, E. F., Petch, J., Clark, A. B., & Gray, R. (2013). The prevalence of metabolic syndrome amongst patients with severe mental illness in the community in Hong Kong—a cross sectional study. BMC Psychiatry, 13, 87. doi:10.1186/1471-244X-13-87 Brunero, S., & Lamont, S. (2009). Systematic screening for metabolic syndrome in consumers with severe mental illness. International Journal of Mental Health Nursing, 18, 144–150. doi:10.1111/j.1447-0349.2009.00595.x Coghlan, R., Lawrence, D., Holman, C. D. J., & Jablensky, A. V. (2001). Duty to care: Physical illness in people with mental illness. Perth: University of Western Australia.
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