Archives of Psychiatric Nursing 28 (2014) 87–93

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu

What Determines Whether Nurses Provide Physical Health Care to Consumers With Serious Mental Illness? Brenda Happell a,⁎, Chris Platania-Phung b, David Scott c a b c

Central Queensland University, Centre for Mental Health Nursing Innovation, Institute for Health and Social Science Research, Bruce Hwy, Rockhampton, Queensland, 4702, Australia Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, and School of Nursing and Midwifery

a b s t r a c t People with serious mental illness (SMI) have heightened rates of chronic physical disease. This study aimed to identify what nurse and organisational factors predict physical health care provided by nurses in contact with consumers with SMI, through a survey in Australia (N = 643). Statistical analyses revealed that physical health care could be accounted for in terms of nurse views on consumer health, rights and nurse role ideal (‘nurses should be involved in physical health care’), and organisational factors. However, organisational factors may be more important in determining physical health care than views and perceptions about consumers, roles and ideals. © 2014 Elsevier Inc. All rights reserved.

People diagnosed with serious mental illness (SMI) have significantly shortened lives due to a higher incidence of physical illness such as cardiovascular disease, diabetes, and cancers (De Hert et al., 2011a). Increased risk of physical illness is due to: poor management of current co-morbidity; social–economic disadvantage; stigma of mental illness; use of second generation anti-psychotics; and lifestyle factors such as poor sleep and high calorie diets (Hardy & Thomas, 2012; Robson & Gray, 2007; Scott & Happell, 2011; Simonelli-Munoz et al., 2012). Despite clear evidence from clinical epidemiology of inequalities in health between people with and without SMI, there is continual demonstration of a neglect of the former group in terms of access to needed physical health care (De Hert et al., 2011b). Poorer access to physical health care for people with SMI is an international issue (Chaudhry, Jordan, Cousin, Cavallaro, & Mostaza, 2010; De Hert et al., 2011b). Health care gaps include screening and identification of chronic physical disease (Scott, Platania-Phung, & Happell, 2011), and reluctance of primary care staff to engage when aware that a consumer has been diagnosed with mental illness (Happell, Scott, Platania-Phung, & Nankivell, 2012; O'Day, Killeen, Sutton, & Lezzoni, 2005; Schmutte et al., 2009). One potential reason for these gaps is that physical health concerns voiced by consumers with SMI are not

Conflict of interest: the authors report no conflict of interest. ⁎ Corresponding Author: Brenda Happell RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD, Central Queensland University, Centre for Mental Health Nursing Innovation, Institute for Health and Social Science Research, Bruce Hwy, Rockhampton, Queensland, 4702, Australia. E-mail addresses: [email protected] (B. Happell), [email protected] (C. Platania-Phung), [email protected] (D. Scott). 0883-9417/1801-0005$34.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnu.2013.11.001

taken at face value by primary care service providers (O'Day et al., 2005; Van Den Tillaart, Kurtz, & Cash, 2009). Improving physical health of people with SMI requires comprehensive approaches in physical health care systems (Lawrence & Kisely, 2010). Mental health care systems are integral as many people with SMI do not have linkage to primary care services (Ministerial Advisory Committee on Mental Health, 2011). Nurses situated in mental health care settings have an important role to play in boosting physical health care access and quality (Blythe & White, 2012; Bradshaw & Pedley, 2012; Happell, Platania-Phung, & Scott, 2011; Muir-Cochrane, 2006; Robson & Gray, 2007), although traditionally they do not play an active role in physical health care provision (Muir-Cochrane, 2006). However, physical health impacts on mental and other dimensions of consumer health (Prince et al., 2007), and nurses as a major group of health care professionals in mental health can respond more assertively to the lack of positive change in physical health of people with SMI (Happell et al., 2011; Robson & Gray, 2007). The literature on the role of mental health nurses in physical health care of consumers include trials of intervention programs or care models aimed at improving physical health prevention and management (Griffiths, Kidd, Pike, & Chan, 2010; Porsdal et al., 2010; Shuel, White, Jones, & Gray, 2010; Smith et al., 2007), qualitative studies of nurse views on the physical health of consumers and health care arrangements (Happell et al., 2011), and inquiries into training needs (Howard & Gamble, 2011; Nash, 2005). As far as we are aware, only one study in the international literature has sought to identify predictors of physical health care (Robson, Haddad, Gray, & Gournay, 2013). In that study, nurses in a Mental Health Trust (N = 585) of the UK were asked about the physical health care they provide. Physical

88

B. Happell et al. / Archives of Psychiatric Nursing 28 (2014) 87–93

health care was significantly predicted by self-reported attitudes of participation in, and confidence in performing physical health care, training background in physical health learning (previous 5 years), nurse grade level, and inpatient employment (Robson et al., 2013). Organisational factors, such as the level of clarity in responsibility on physical health care among health care teams, were not investigated. This may be because in the UK there is policy on physical health care responsibilities (Department of Health, 2006) compared to places, such as Australia, where governance of physical health care in mental health services is less clear and more diverse. There has yet to be a direct investigation of nurse views and attitudes, and organisational factors as potential predictors of nurse physical health care. Given that an enhanced role of physical health care by nurses is a potential pathway of improving consumer well-being (Bradshaw & Pedley, 2012; Muir-Cochrane, 2006), predictive factors for current practices may represent foci for increasing physical health care. This study aimed to determine what nurse and organisational factors predict a spectrum of physical health care practices by nurses in Australia. It was hypothesized that four groups of variables (nurse background, nurse views of consumer health, nurse attitudes on involvement and view of rights to care, and organisational factors) would predict physical health care. The specific variables in each group that may significantly predict types of physical health care were an open empirical question to be addressed in this study. METHODS Design This was a cross-sectional study, employing an online survey of nurses employed in mental health settings in Australia. To gain the best possible representative sample of nurses across Australia, participants were accessed via the electronic membership list of the Australian College of Mental Health Nurses (ACMHN), the professional body representing nurses working in mental health. The study was approved by a university-based human research ethics committee. Participation was voluntary and consent was indicated by responding to the online survey. To ensure full survey responses, it was required that closed format questions be completed in order to proceed through the survey. Email reminders was sent by the ACMHN, to gain as high a sample size as possible. Measures The survey was largely composed of newly formulated questions as well as two selected scales from the Physical Health Attitude Scale (PHASe) (Robson & Haddad, 2012), developed in the UK, and utilised in the only other study available that looked at predictors of nurse physical health care of consumers with SMI in that region (Robson et al., 2013). This measure was adopted after gaining permission from the lead developer of that measure. Other items of the survey were developed to suit the context of Australia and to operationalize viewpoints of nurses that were identified in an earlier qualitative study by the researchers (Happell et al., 2012). The new items and PHASe scales adopted for the survey were pilot tested with a group of adults involved in public health. The survey was found to be highly comprehensible and easy to respond to, and minor revisions were made to questions as a result of feedback. A set of questions of nurse background were included such as gender, years as nurse, type of mental health setting, and whether or not credentialed as a mental health nurse (which is governed and administered by the ACMHN). Nurse perceptions of consumer physical health (to be described herein as ‘physical ill-health’) were investigated by asking participants to ‘rate’ consumer health with the general community as a reference point, specifically: How would you rate the health of consumers of MH services, compared to members of

the wider community? The specified health disorders were cardiovascular disease, diabetes, respiratory conditions and oral– dental conditions. The response options were: ‘much worse’, ‘somewhat worse’, ‘about the same’, ‘somewhat better’, and ‘much better’. Consumer lifestyle behaviours were inquired about as follows: “In your opinion, in general what is the level of health problems among consumers of MH services, compared to members of the general community?” The behaviours were: poor diet, physical inactivity, excessive alcohol use, smoking, poor sleep behaviour, illicit drug use, and unsafe sex. The response options were the same as for the question on consumer physical health, just described. To minimise the number of predictor variables, nurse perceptions of consumer physical health and behaviour were submitted to principal components analysis to explore whether the responses formed two composite variables. Communalities ranged from .47 to .67. The first two eigenvalues accounted for 56% of item variance. The pattern matrix showed clear differentiation between the items on physical health problems and the items on risk behaviours. Items for each set were summed to create scales. Higher scores represented perceived higher physical health of consumers with SMI. The internal consistency level of perceived consumer health was .84, and that of perceived consumer risk behaviours was .83. The remaining independent variables were based on participant responses to statements in terms of (dis)agreement level. Nurse perceptions of consumer and nurse roles, and organisational factors were measured via nurse self-report, in terms of level of agreement with statements rated from 1 (‘strongly disagree’) to 5 (‘strongly agree’). On consumer rights and nurse role the variables were: nurse responsibility (‘Nurses in mental health settings should be involved in physical health care of mental health consumers’), consumer rights (‘Consumers have a right to physical health care from mental health care services’). There was also a single statement drawn from the PHASe (Robson & Haddad, 2012, p. 77), to measure what will be called “consumer health worries”; the statement was “Consumers' health worries are mostly due to their mental illness”. In terms of organisational factors, the variables were: team meetings (‘The physical health of consumers is often discussed during mental health care team meetings’), clarity of responsibility (‘There are clear lines of responsibility on physical health care of consumers, for each staff member in the team’), and presence of a lifestyle program (‘We have a lifestyle program available for consumers’). The measure of physical health care was also drawn from the larger PHASe set of questions (Robson & Haddad, 2012). Health care actions [called “physical health-care practices” by Robson et al. (2013, p. 6)], were presented, such as “monitoring consumer's blood pressure”. The rating response scale was: 1 (‘never’), to 5 (‘always’). This set of items addressed the following types of physical health care: advice provision, such as “giving consumers advice on dental health”; assessment, such as “testing consumers on glucose abnormalities (e.g. checking glucose in urine)”; general practitioner (gp)/assessment on entry, such as “checking if consumers have had their general physical health assessed when they first came into contact with our service”, drugs and alcohol, such as “providing consumers with information and support to stop or reduce drug use”; and lifestyle education, such as “helping consumers manage their weight”. Two changes were made to PHASe to suit the purposes of the current study. The prompt to the list of health care actions was changed to read as: “How often do you undertake each of the following practices with consumers?” In addition, four health care actions relevant to consumer physical health were added (ensuring regular eyesight assessment, advice on STD protection, and informational support in stopping or reducing drug use and alcohol intake).

B. Happell et al. / Archives of Psychiatric Nursing 28 (2014) 87–93

Statistical Methodology Latent variable modelling was applied in order to address measurement error of the observed dependent variable. A measurement model of nurse physical health care was first tested. An earlier analysis based on principal components suggested that the questions on physical health care were multi-dimensional, but that there was evidence for an engagement in physical health care as there were statistically significant and positive correlations between all specific types of physical health care (Happell, Platania-Phung, & Scott, 2013). The purpose of the measurement model was to test whether an overall (latent) physical health care variable was warranted. These analyses were conducted with Mplus Version 6.1. Model fit was assessed on a group of indices (Byrne, 2012): χ 2 statistic with a P-value of over .05; a root mean square error of approximation (RMSEA) of under .08, and 90% confidence interval where the higher interval is under .08 suggesting a well-fitting model; a root mean square residual (RMSR) of under .05; a comparative fit index (CFI) of over .95; and a Tucker Lewis Fit Index (TLI) of over .95. As there were issues of non-normality in the data, the Satorra and Bentler χ 2 was used (cf. Byrne, 2012), that is implemented through MLMV estimation in Mplus. Nine independent variables were planned as predictors of nurse physical health care. Two variables on nurse background were included as they were found to be to be associated with some domains of physical health through an earlier, exploratory analysis (Happell et al., 2013)—gender and possession of credential as a mental health nurse. Three variables tapping nurse perceptions of their consumers were included as potential precursors: relative physical health of consumer (compared to general population), relative risk behaviours of consumers (compared to general population), and perceived legitimacy of consumer's physical health worries. Also included were two views: on the ideal of nurses committing to physical health care and on consumer with SMI rights to physical health care. The organisation-related variables in the model were: physical health of consumers with SMI as discussed in team meetings, the presence of a lifestyle program at the health setting, the presence of clear responsibility among the team for physical health care, and nurse views of whether workload was a barrier to nurse-based health. There were no missing data in the current study, as the survey was set so that participants were required to provide a response to all closed format questions. RESULTS The final sample was 643. Table 1 displays the participants' characteristics. Females made up 72.7% of the sample. The most represented health setting was publicly-run mental health services (70.3%). Those who had worked as a nurse for 21 to 40 years represented 62.5% of participants. Almost half of participants reported being community nurses. Table 2 presents the descriptive information for the variables contained in the structural equation latent variable model. The descriptive information in Table 2 suggests that on the whole, participants viewed the physical health of consumers with SMI as lower than that of the general community, as well as taking part in a higher rate of risky lifestyle behaviours. Table 2 shows that there was a high level of agreement with the statements that nurses in mental health services should provide physical health care, and that consumers have a right to physical health care in mental health. The variables for each of the physical health care domains (e.g. assessments, lifestyle advice) were based on composites of items. In general, participants reported to do physical health care activities on a regular basis, and particularly lifestyle education. Table 3 shows the inter-correlations between all variables planned for the latent variable model. It can be seen

89

Table 1 Participant Characteristics. Background Gender Female Male Missing ACMHN credentials Has credentials No credentials State or territory Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Mental health service Public Private or other non-government Other Not in mental health service Duration (years) as nurse 0–10 11–20 21–30 31–40 Over 40 years Current nursing role⁎ Inpatient Community Other Missing

n

%

468 175 1

72.7% 27.2% 0.2%

271 372

42.1% 57.8%

11 175 12 163 48 17 154 63

1.7% 27.2% 1.9% 25.3% 7.5% 2.6% 23.9% 9.8%

453 106 68 16

70.3% 16.4% 10.6% 2.5%

101 112 209 193 26

15.7% 17.4% 32.5% 30.0% 4.0%

142 309 264 1

22.0% 48.0% 41.1% 0.2%

⁎ Do not sum to 100% as participants could indicate multiple roles.

from Table 3 that the largest correlations were between the domains of physical health care. A confirmatory factor model was tested, where the domains of physical health care were treated as indicator variables of a hypothesized latent variable defined as physical health care. There was mixed evidence for model fit: Satorra–Bentler χ 2(5) = 34.67, P = .00, CFI = .97, TLI = .94, RMSEA = .10 (.07, .13), SRMR = .03. The standardized residuals indicated that the model did not take into account correspondences between drug and alcohol with multiple domains of other care, and thus, evidence that it was a cross-loading indicator. As drug and alcohol were taken as a redundant indicator on this basis, it was removed, and a subsequent confirmatory factor model tested. The revised model demonstrated good model fit: Table 2 Descriptive Statistics for Variables. Precursors:

Range

Physical ill-health Lifestyle behaviours Consumer health worries Consumer rights Nurse responsibility Team meetings Clarity of responsibility Workload barrier Lifestyle program

5–25 7–24 1–5 1–5 1–5 1–5 1–5 1–5 1–5

M (SD) 7.81 11.30 2.29 4.22 4.46 3.47 2.89 2.35 3.07

(2.53) (3.22) (0.89) (0.87) (0.72) (1.07) (1.14) (1.10) (1.25)

Skewness

Kurtosis

1.03 0.68 0.77 −1.15 1.94 −0.47 0.14 0.80 −0.06

2.70 −0.30 0.30 1.20 6.12 −0.63 −0.90 −0.24 −1.15

0.09 0.60 −0.28 −1.35

−0.59 0.20 −0.40 3.13

Physical health care domains: Advice provision Giving Drug and alcohol Lifestyle education

5–25 4–20 2–10 12–35

14.93 10.22 7.26 31.03

(4.86) (3.50) (1.93) (3.42)

NOTE. The standard error for skewness was .10, and the standard error for kurtosis was .19.

B. Happell et al. / Archives of Psychiatric Nursing 28 (2014) 87–93 1.00 1.00 .32⁎⁎⁎ −.14⁎⁎⁎ .25⁎⁎⁎ .29⁎⁎⁎ .23⁎⁎⁎

.15⁎⁎⁎ .26⁎⁎⁎ .13⁎⁎ .18⁎⁎⁎ .12⁎⁎ .17⁎⁎⁎ −.08⁎ −.18⁎⁎⁎

1.00 .05 .06 .01 −.02 −.01 .02 −.07 −.11⁎⁎ .14⁎⁎⁎ −.12⁎⁎ .05 −.12⁎⁎

1.00 .37⁎⁎⁎ −.03 −.14⁎⁎ −.10⁎⁎ .07 .10⁎⁎ −.02 .03 0.10⁎ −.07 −.02 −.08 −.09⁎

1.00 −.08⁎ −.08⁎ −.11⁎⁎ −.00 −.07 −.07 −.04 −.15⁎⁎⁎ −.02 −.06 −.25⁎⁎⁎ −.11⁎⁎

1.00 −.03 .03 .01 .03 .01 .18⁎⁎⁎ −.06 −.03 −.07 −.06 −.10⁎

1.00 .38⁎⁎⁎ .01 .06 .08⁎ −.13⁎⁎ .17⁎⁎⁎ .25⁎⁎⁎ .08⁎

1.00 .03 .12⁎⁎ .08 −.08⁎ .11⁎⁎ .20⁎⁎⁎ .00 .06 .11⁎⁎

1.00 .46⁎⁎⁎ .25⁎⁎⁎ −.12⁎⁎ .20⁎⁎⁎ .24⁎⁎⁎ .23⁎⁎⁎

1.00 −.16⁎⁎⁎ .30⁎⁎⁎ .30⁎⁎⁎ .18⁎⁎⁎ .20⁎⁎⁎ .30⁎⁎⁎

1.00 −.23⁎⁎⁎ −.16⁎⁎⁎ −.25⁎⁎⁎ −.14⁎⁎⁎ −.28⁎⁎⁎

1.00 .55⁎⁎⁎ .39⁎⁎⁎ .53⁎⁎⁎ .68⁎⁎⁎

1.00 .53⁎⁎⁎ .30⁎⁎⁎ .56⁎⁎⁎

1.00 .39⁎⁎⁎ .46⁎⁎⁎

15 14 13 12 11 10 9 8 7 6 5 4 3 2†

The current study has advanced research by identifying factors that may affect the regularity of nurse physical health care of consumers with SMI in Australia. The novel finding of this study was that the most consistent and salient factors in physical health care were organisational arrangements, such as ensuring responsibilities for physical health care were clear, discussion of physical health of consumers at meetings, the presence of a lifestyle program in the service, and the nurses' workloads. Two nurse-based perceptions of consumers with SMI (relative to the ‘general community’) predicted physical health care: risky lifestyle behaviours, and in a negative way, the view that consumer worries on physical health are due to their mental illness. Furthermore, the view that nurses should be involved in physical health care significantly predicted self-reported physical health care. Overall, actions by health care organisations to focus on care practices may be the most important aspect of increasing and ensuring access to physical health care of consumers with SMI through nurses. As far as the authors are aware, this is the first quantitative study of predictors of physical health care of nurses in a mental health care context in Australia. A study conducted in the UK (Robson et al., 2013)

1.00 −.05 −.08 −.15⁎⁎⁎ .01 −.04 .02 .04 −.00 .02 −.04 .10⁎ .06 .14⁎⁎⁎ .08⁎ .12⁎⁎

1†

DISCUSSION

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

.80 ⁎ P b .05. ⁎⁎ P b .01. ⁎⁎⁎ P b .001. † Biserial correlations.

Variable

Gender MHN credential Physical ill-health Lifestyle behaviours Consumer health worries Nurse responsibility Consumer rights to care Meetings Clarity of responsibility Lifestyle program Workload as barrier Advice provision Assessment and Monitoring GP and assessment on entry Drug and alcohol Lifestyle

Table 3 Pearson Correlations Between Nurse Background and Views, and Domains of Physical Health Care.

Satorra–Bentler χ 2 (2) = 3.40, P = .18, CFI = .10, TLI = .99, RMSEA = .03 (90%CI: .00, .09), SRMR = .01. Figure 1 shows the factor loadings for each of the physical health care indicators. It indicates that factor loadings ranged from .52 to .85. The internal consistency of the group of indicators for physical health care was .77. The full latent variable model was then tested. There was mixed evidence for model fit: Satorra–Bentler χ 2(35) = 130.59, P = .00, CFI = .92, TLI = .89, RMSEA = .06 (.05, .08), SRMR = .03. The percentage of variance of physical health care accounted for by the model was 31.5% (t = 8.43, P b .05). Gender predicted physical health care (β = .10, t = 2.71, P b .05). Member of the ACMHN did not differentiate physical health care (β = − .05, t = 1.24, P N .05). Of perceptions on relative health of consumers with SMI, health did not predict physical health care (β = − .07, t = − 1.24, P N .05), nor did risk behaviour (β = − .06, t = − 1.43, P N .05). In terms of nurse views on responsibilities and consumer rights, it was the view that nurses should be involved in physical health care, that predicted overall physical health care (β = .14, t = 3.88, P b .05), while the view on consumer rights did not (β = .03, t = 0.73, P N .05). The view that “consumer physical health worries are mostly due to their mental illness” predicted a lower level of physical health care (β =− .08, t = − 2.17, P b .05). All organisation-related variables were significant predictors of more nurse self-reported physical health care: team meetings (β = .10, t = 2.30, P b .05), clear lines of responsibility (β = .18, t = 4.14, P b .05), workload as barrier to physical health care (β = .19, t = −4.84, P b .05), and presence of a lifestyle program (β = .23, t = 5.94, P b .05). Comparing the size of t-statistics for the independent variables, organisational factors tended to have larger effects on physical health care, than nurses' perceptions and views in relation to consumers and the role of mental health services and nurses in physical health care.

1.00 .56⁎⁎⁎

16

90

Physical Health Care

Give advice

.67

Assessments

.52 .85

GP linkage Lifestyle

Fig 1. Confirmatory factor model of nurse physical health care.

B. Happell et al. / Archives of Psychiatric Nursing 28 (2014) 87–93

also examined physical health care as an outcome variable, and the current study adopted the nurse physical health care scale (and some other questions) that were developed by these researchers. However a number of differences between the studies make comparison of results difficult. The previous study (Robson et al., 2013) was conducted at an earlier period (2006–2007), was in a different health care context (UK), and examined nurse attitudes and beliefs in more detail while not looking at organisational factors, other than workload as barrier. Additionally, 70% of participants in the Robson study were inpatient nurses; in the current study it was 22%. Two variables from the PHASe scale “nurses' perceived barriers to physical health-care delivery” were included in the current statistical model: perceived workload and physical health worries of consumer. The consistency in findings between the two studies is that, in general, differences in nurse background, perceptions and attitudes do significantly predict self-reported physical health care. However, as will be discussed, other forms of nurse perceptions may play a role and organisational arrangements may be important. Nurses generally viewed consumers with SMI as having lower physical health and engaging in riskier lifestyles, and these views are consistent with comparisons of patterns of health and healthrelated behaviour reported in the empirical research literature (Scott & Happell, 2011). It is sometimes assumed that staff views on the risks to a consumer group may increase the level of staff care actions; this assumption was not supported by the current findings. As education of nurses on the elevated physical health problems of people with SMI may still be a ‘leverage’ for more health care actions, the issue of nurse perceptions and views of consumer health warrant further investigation. The belief that consumer worries about physical health may reflect symptomology of their mental illness was a statistically significant predictor of self-reported physical health care. This finding corroborates what has been identified in studies of health care staff and consumer experiences, that a lack of care responsiveness by health service providers can result from those providers equating expression of physical health issues with mental illness (Mental Health Council of Australia, 2005; O'Day et al., 2005; Schmutte et al., 2009; Van Den Tillaart et al., 2009). Although the regularity of this type of event is not known, it definitely represents a scenario where legitimate health problems go undetected or untreated. In the mental health sector of Australia, practice guidelines may be needed that alert nurses not to downplay the physical health concerns of consumers with SMI and how to follow up on the voicing of such concerns (e.g. direct physical health assessment, referral for screening by a specialist). It is argued in the literature that nurses should be involved in the physical health care of consumers with SMI (Robson & Gray, 2007). In the UK study (Robson et al., 2013), this was conceived as a type of nurse attitude and was found to predict overall nurse physical health care. Although the current study provided a different and less detailed measure than the UK study, it provides further evidence that the view that nurses “should be involved in physical health care” is linked to more frequent physical health care. One implication of this finding is that efforts to affirm that mental health nurses can contribute to better physical health care access (e.g. Muir-Cochrane, 2006), may promote nurse-provided care in day-to-day clinical work. Turning now to the organisational factors, through the current quantitative approach we were able to substantiate major assumptions in the literature, such as that perceptions of responsibility may improve the likelihood that physical health care is conducted (Wheeler et al., 2010). In the literature on physical health care of consumers with SMI, the role of this organisational arrangement had not been directly investigated in a definitive way (i.e. quantitative and controlled field study). Rather, it has been

91

suggested that shared understandings or rules on responsibility would encourage nurse involvement in physical health care (Wheeler et al., 2010). Having detailed requirements for mental health nurses in physical health has been emphasised in UK policy (Department of Health, 2006), in contrast to Australia where there has been little development of the physical health role of mental health nurses. The current findings confirm that organisational measures to clarify responsibilities may indeed be an important component on supporting nurses in their physical health initiatives with consumers with SMI. Another significant organisational predictor of physical health care actions by nurses was the establishment of a lifestyle program for consumers with SMI, having a bearing on all domains of care except drug and alcohol. Lifestyle programs may help sustain attention of consumers and nurses on physical health issues and provide positive support to the day-to-day care. Research on lifestyle programs for physical health prevention and management is steadily increasing (e.g. see Bradshaw, Lovell, & Harris, 2005; Park, Usher, & Foster, 2011), and is valued by consumers with SMI (e.g. see Shiner, Whitley, Van Citters, Pratt, & Bartels, 2008). The current findings suggest that a positive by-product of lifestyle programs is to foster nurse physical health care. Therefore lifestyle-based initiatives are further encouraged here, as well as further research to identify how lifestyle programs help nurses engage with consumers on physical health issues. Workload appears to be another organisational factor influencing nurses' involvement in physical health care. The current finding of workload predicting less physical health care in five of the seven domains is broadly consistent with findings of qualitative research where nurses indicate demands of their work make it difficult to look at physical health; and that the usual focus of mental health nursing on mental illness and crisis management being demanding on its own (Henderson, Willis, Walter, & Toffoli, 2008). There were some limitations to the current study. First, this study had a low response rate (22.2%, based on 643 responses to an estimated membership pool of 2900). This may be a reflection on the population of interest, as another online study of the overall membership body gained a lower response rate than the current one (7.8%) (Marks, 2012), and the current response rate is likely an underestimate of the true response rate as electronic addresses and membership lists are likely to have contained errors. As shown in Table 1 the sample did include nurses from all states and territories of Australia, which is significant given the geographical size of this country. Nevertheless, as selection was non-random and the response rate low, the generalizability of the findings is not clear and further studies are required to be more confident that organisational factors are indeed primal on nurse physical health actions in mental health services. Second, as this was a crosssectional study, causative relations could not be established with respect to nurse physical health care. One could easily conceive that nurse physical health care may affect their perceptions and views on consumer health and on organisational factors, rather than the latter being antecedent variables; bi-directional relationships are also plausible. Third, in order to ensure that data were not identifiable, it was not known whether there was a hierarchical structure to the data (e.g. multiple participants nested in workplaces) and so it was not possible to test for multi-level effects. As the current research identified that organisational variables are important, and that the causative status of variables is yet to be established, further research should adopt a hierarchical and repeated measures design (e.g. longitudinal and multi-level models; see Hox, 2010). There remained ‘unexplained variance’ in nurse physical health care. We anticipate that addressing other nurse views and attitudes, such as in the work already done by Robson and Haddad (2012), would increase predictive efficacy. Importantly, the current findings

92

B. Happell et al. / Archives of Psychiatric Nursing 28 (2014) 87–93

indicate that more comprehensive investigation of organisational variables in needed also, as arrangements in care seemed to play a stronger role than nurse perceptions and views. Finally, developing research on nurse physical health care requires a theoretical framework where individual beliefs, views and perceptions are considered, but also the practices that take place in mental health services. Social practice theory (Hargreaves, 2011) is an approach that should be explored for this purpose. In social practice theory, to understand and move towards desired practices (e.g. physical health care by nurses) requires attention to day-to-day “doings” and what local features of the social environment may sustain them (Hargreaves, 2011; see also Warde, 2005). Social practice theory retains consideration of individual level thoughts and beliefs, but offers a broadened framework, whereby co-ordination of practices is the focus rather than changes in attitudes (Hargreaves, 2011). To conclude, the current findings indicate that what counts in nurse-based access to physical health care of consumers with SMI is what gets done in health care services, such as clearly defining responsibilities, attention to physical health in meetings, and implementation of lifestyle programs. Nurse thoughts and views on consumers and ideals may be of secondary or less reliable import to whether they conduct physical health care. Acknowledgment The authors would like to thank the nurse participants for their time and valuable input. Our thanks to the Australian College of Mental Health Nurses, particularly Kim Ryan and Haylie Maylia for their invaluable assistance in distributing the survey. Research Advancement Award Scheme and Merit Grant Scheme of Central Queensland University provided the funding to make this work possible. References 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, http://dx.doi.org/ 10.1111/j.1447-0349.2011.00792.x. Bradshaw, T., Lovell, K., & Harris, N. (2005). Healthy living interventions and schizophrenia: A systematic review. Journal of Advanced Nursing, 49(6), 634–654, http://dx.doi.org/10.1111/j.1365-2648.2004.03338.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, http://dx.doi.org/10.1111/j.14470349.2012.00818.x. Byrne, B. M. (2012). Structural equation modelling with Mplus. London: Routledge. Chaudhry, I. B., Jordan, J., Cousin, F. R., Cavallaro, R., & Mostaza, J. M. (2010). Management of physical health in patients with schizophrenia: International insights. European Psychiatry, 25(Suppl 2), S37–S40, http://dx.doi.org/ 10.1016/ S0924-9338(10)71705-3. De Hert, M., Cohen, D., Bobes, J., Cetkovich-Bakmas, M., Leucht, S., Ndetei, D. M., & Correll, C. U. (2011a). Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry, 10(2), 138–151. De Hert, M., Correll, C. U., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., & Leucht, S. (2011b). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry, 10(1), 52–77. Department of Health. (2006). Choosing health: Supporting the physical health needs of people with severe mental illness: Commissioning framework. London: Department of Health Publications. Griffiths, M., Kidd, S. A., Pike, S., & Chan, J. (2010). The tobacco addiction recovery program: Initial outcome findings. Archives of Psychiatric Nursing, 24(4), 239–246, http://dx.doi.org/10.1016/j.apnu.2009.07.003. Happell, B., Platania-Phung, C., & Scott, D. (2011). Placing physical activity in mental health care: A leadership role for mental health nurses. International Journal of Mental Health Nursing, 20(5), 310–318, http://dx.doi.org/10.1111/j.14470349.2010.00732.x. Happell, B., Platania-Phung, C., & Scott, D. (2013). Are nurses in mental health services providing physical health care for people with serious mental illness? An Australian perspective. Issues in Mental Health Nursing, 34, 198–207. Happell, B., Scott, D., Platania-Phung, C., & Nankivell, J. (2012). Should we or shouldn't we? Mental health nurses' views on physical health care of mental health consumers.

International Journal of Mental Health Nursing, 21(3), 202–210, http://dx.doi. org/10.1111/j.1447-0349.2011.00799.x. Hardy, S., & Thomas, B. (2012). Mental and physical health comordibity: Political imperatives and practice implications. International Journal of Mental Health Nursing, 21(3), 289–298. Hargreaves, T. (2011). Practice-ing behaviour change: Applying social practice theory to pro-environmental behaviour change. Journal of Consumer Culture, 11(1), 79–99. Henderson, J., Willis, E., Walter, B., & Toffoli, L. (2008). Community mental health nursing: Keeping pace with care delivery? International Journal of Mental Health Nursing, 17(3), 162–170, http://dx.doi.org/10.1111/j.1447-0349.2008.00528.x. Howard, L., & Gamble, C. (2011). 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, http://dx.doi.org/10.1111/j.1365-2850.2010.01642.x. Hox, J. J. (2010). Multilevel analysis: Techniques and applications (2nd ed.)New York, NY: Routledge. Lawrence, D., & Kisely, S. (2010). Review: Inequalities in healthcare provision for people with severe mental illness. Journal of Psychopharmacology, 24(4 Suppl), 61–68. Marks, P. (June-August 2012). Review of the ACMHN strategic plan 2009-2012: analysis of member views. : News: Australian College of Mental Health Nurses, 5. Mental Health Council of Australia. (2005). Not for service: Experiences of injustice and despair in the mental health care in Australia. Canberra: Mental Health Council of Australia. Ministerial Advisory Committee on Mental Health. (2011). Improving the physical health of people with severe mental illness. Melbourne: Ministerial Advisory Committee on Mental Health, Victorian Department of Health. Muir-Cochrane, E. (2006). Medical co-morbidity risk factors and barriers to care for people with schizophrenia. Journal of Psychiatric and Mental Health Nursing, 13(4), 447–452, http://dx.doi.org/10.1111/j.1365-2850.2006.01002.x. Nash, M. (2005). Physical care skills: A training needs analysis of inpatient and community mental health nurses. Mental Health Practice, 9(4), 20–23. O'Day, B., Killeen, M. B., Sutton, J., & Lezzoni, L. I. (2005). Primary care experiences of people with psychiatric disabilities: Barriers to care and potential solutions. Psychiatric Rehabilitation Journal, 28(4), 339–345. Park, T., Usher, K., & Foster, K. (2011). Description of a healthy lifestyle intervention for people with serious mental illness taking second-generation antipsychotics. International Journal of Mental Health Nursing, 20(6), 428–437, http://dx.doi. org/10.1111/j.1447-0349.2011.00747.x. Porsdal, V., Beal, C., Kleivenes, O. K., Martinsen, E. W., Lindstrom, E., Nilsson, H., & Svanborg, P. (2010). The Scandinavian Solutions for Wellness study—A two-arm observational study on the effectiveness of lifestyle intervention on subjective well-being and weight among persons with psychiatric disorders. BMC Psychiatry, 10, 42 (doi: 1471-244X-10-42 [pii]). Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M. R., & Rahman, A. (2007). No health without mental health. Lancet, 370(9590), 859–877, http://dx.doi.org/10.1016/ S0140-6736(07)61238-0. Robson, D., & Gray, R. (2007). Serious mental illness and physical health problems: A discussion paper. International Journal of Nursing Studies, 44(3), 457–466, http://dx.doi.org/10.1016/j.ijnurstu.2006.07.013. 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, http://dx.doi.org/10.1016/j.ijnurstu.2011.07.011. Robson, D., Haddad, M., Gray, R., & Gournay, K. (2013). Mental health nursing and physical health care: A cross-sectional study of nurses' attitudes, practice, and perceived training needs for the physical health care of people with severe mental illness. International Journal of Mental Health Nursing, 22(5), 409–417. Schmutte, T., Flanagan, E., Bedregal, L., Ridgway, P., Sells, D., Styron, T., & Davidson, L. (2009). Self-efficacy and self-care: Missing ingredients in health and healthcare among adults with serious mental illnesses. Psychiatric Quarterly, 80(1), 1–8, http://dx.doi.org/10.1007/s11126-008-9088-9. Scott, D., & Happell, B. (2011). The high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness. Issues in Mental Health Nursing, 32(9), 589–597, http://dx.doi.org/10.3109/ 01612840.2011.569846. Scott, D., Platania-Phung, C., & Happell, B. (2011). Quality of care for cardiovascular disease and diabetes amongst individuals with serious mental illness and those using antipsychotic medications. Journal of Healthcare Quality, 34(5), 15–21, http://dx.doi.org/10.1111/j.1945-1474.2011.00155.x. Shiner, B., Whitley, R., Van Citters, A., Pratt, S. I., & Bartels, S. J. (2008). Learning what matters for patients: Qualitative evaluation of a health promotion program for those with serious mental illness. Health Promotion International, 23(3), 275–280. Shuel, F., White, J., Jones, M., & Gray, R. (2010). Using the serious mental illness health improvement profile [HIP] to identify physical problems in a cohort of community patients: A pragmatic case series evaluation. International Journal of Nursing Studies, 47(2), 136–145, http://dx.doi.org/10.1016/j.ijnurstu.2009.06.003. Simonelli-Munoz, A. J., Fortea, M. I., Salorio, P., Gallego-Gomez, J. I., Sanchez-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, http://dx.doi.org/10.1111/j.1447-0349.2012.00821.x. Smith, S., Yeomans, D., Bushe, C. J., Eriksson, C., Harrison, T., Holmes, R., & Sullivan, G. (2007). A well-being programme in severe mental illness. Reducing risk for physical ill-health: A post-programme service evaluation at 2 years. European Psychiatry, 22(7), 413–418, http://dx.doi.org/10.1016/j.eurpsy.2007.07.002. Van Den Tillaart, S., Kurtz, D., & Cash, P. (2009). Powerlessness, marginalized identity, and silencing of health concerns: Voiced realities of women living with a mental

B. Happell et al. / Archives of Psychiatric Nursing 28 (2014) 87–93 health diagnosis. International Journal of Mental Health Nursing, 18(3), 153–163, http://dx.doi.org/10.1111/j.1447-0349.2009.00599.x. Warde, A. (2005). Consumption and theories of practice. Journal of Consumer Culture, 5 (2), 131–153.

93

Wheeler, A., Harrison, J., Mohini, P., Nardan, J., Tsai, A., & Tsai, E. (2010). Cardiovascular risk assessment and management in mental health clients: Whose role is it anyway? Community Mental Health Journal, 46(6), 531–539, http://dx.doi.org/ 10.1007/s10597-009-9237-0.