training practice nurses to improve the physical health of patients with severe mental illness:...

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Training practice nurses to improve the physicalhealth of patients with severe mental illness:Effects on beliefs and attitudes

Sheila HardyPark Avenue Medical Centre, University of East Anglia, Northampton, UK

ABSTRACT: Annual health checks are recommended for patients with severe mental illness (SMI) asthey are at high risk of cardiovascular disease. Ideally, these health checks should be carried out inprimary care. Practice nurses are already competent in carrying out physical health checks, but mighthave misconceptions about mental illness, which is a barrier to offering the service. We used a mirrorimaging study to establish the effectiveness of a training package for practice nurses that aims toaddress common misconceptions about the physical health of people with SMI. This 2-hour trainingpackage (Northampton Physical Health and Wellbeing Project) was delivered to eight practice nurses.Their misconceptions and beliefs were assessed before and after training. Motivation to work withcommunity mental health workers was assessed after training. The practice nurses involved in thestudy rejected commonly held misconceptions about the physical health of people with SMI aftertraining. Their attitudes towards their role in providing health checks appeared to be modified in apositive direction. Their motivation to work with community mental health workers also seemed to beenhanced. The Northampton Physical Health and Wellbeing Project training was effective in modify-ing practice nurses’ misconceptions about physical health in people with SMI.

KEY WORDS: education, physical health check, practice nurse, primary care, severe mental illness.

BACKGROUND

Due to a combination of lifestyle factors and the sideeffects of antipsychotic medication, there is a high inci-dence of cardiovascular disease (CVD) causing prematuredeath in people with SMI (Filik et al. 2006; Hennekenset al. 2005). Therefore, it is necessary that these patientshave an annual physical health check to identify riskfactors for CVD. There is little evidence to show thatthese health checks are routinely taking place (Hardyet al. 2011; Roberts et al. 2007).

People generally attend primary care for routine healthmonitoring and, therefore, it is the best place for people

with SMI to receive screening (Osborn et al. 2007). Prac-tice nurses are already competent in carrying out physicalhealth checks (Osborn et al. 2010), but misconceptionsabout people with mental illness might be a barrier toaccepting this as part of their routine work. Lester et al.(2005) discovered that primary care doctors and practicenurses largely believed that the care of people with SMIwas too specialized for their service. Even if practicenurses are not inviting patients with SMI to attend for aphysical health check, this group might still present them-selves for other reasons (Harvey et al. 2005) (e.g. coughs,cuts, and rashes).

Up to 50% of patients with SMI in the UK receive helpfrom a mental health professional in secondary care(BMA & NHS Employers 2011) who could have a role inensuring a health check has taken place in primary care(Osborn et al. 2010). We believe that as practice nursesare not used to working specifically with people with SMI,

Correspondence: Sheila Hardy, 168 Park Avenue Medical Centre,Park Avenue North, Northampton NN3 2HZ, UK. Email: [email protected]

Sheila Hardy, RMN, RGN, BSc (Hons), MSc.Accepted November 2011.

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International Journal of Mental Health Nursing (2012) 21, 259–265 doi: 10.1111/j.1447-0349.2011.00800.x

© 2012 The AuthorInternational Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

they are unlikely to have a system for informing commu-nity mental health workers (CMHW) about patients thatthey have invited for a health check. A survey of practicenurses revealed that only 7% have regular contact with acommunity psychiatric nurse (Gray et al. 1999). It is pos-sible that if CMHW attend practice nurse training, col-laborative working might be promoted between primaryand secondary care.

A systematic search with the aim of evaluating thecurrent evidence of the efficacy of education interven-tions for improving the physical health of people withSMI yielded no studies (Hardy et al. 2011). In ourview, a focused training delivered in the practice settingmight be effective in breaking down practice nurses’misconceptions.

To meet these needs, we developed a training package(the Northampton Physical Health and WellbeingProject) with funding from a primary care service pro-vider in the Midlands, UK. Two tools have already beendeveloped that guide health professionals and red flaghealth problems: the Physical Health Check (Rethink2008) and the Serious Mental Illness Health Improve-ment Profile (HIP) (White et al. 2009). Both tools wouldneed adaptation to fit the needs of primary care as in theUK, each GP practice uses a computerized system torecord patient consultations, and not all practices have thesame system. One advantage of using one of these systemsis that elements of the consultation can be coded and,therefore, data collection is very straightforward. Regret-tably, at present, these individual systems are not compat-ible with other computer programmes. Using either toolas they stand would mean that the nurse would have torecord the information twice, potentially leading to addi-tional error and data conflicts. The HIP was chosen as themost suitable tool as there is positive qualitative evidencethat using it results in improved health (Schuel et al.2009).

The overall aim of this study was to increase the pro-portion of patients in participating practices that have hadan assessment of cardiovascular risk. We aimed to facili-tate this by addressing misconceptions and increasing themotivation of practice nurses to do a health check. This isimportant, as without this understanding, the reasonsfor any change in patient outcomes are impossible todetermine (Hardy et al. 2011).

OBJECTIVE

The objective of the present study was to ascertainwhether the Northampton Physical Health and WellbeingProject training package is effective in modifying practice

nurses’ attitudes and misconceptions about the physicalhealth of people with SMI and increases motivation towork with CMHW.

METHOD

This is a within-subjects mirror-image study. Practicenurses participating in the study were asked to completetwo questionnaires immediately before and directly aftertraining (misconceptions and attitudes). Their motivationto work with CMHW was assessed straight after training.Post-examination was carried out immediately due to thedifficulty in gaining access to practice nurses.

Preparing primary care practices for trainingPrior to inviting GPs to participate in training, weattended one of their regular meetings, where a repre-sentative from all 31 practices in Northampton is usuallypresent. We carried out a presentation describing theproject and what they would need to do to participate. Aletter was sent (with accompanying detailed information)to each GP practice representative. A practice nurse wasidentified from each practice to be the project lead fortheir organization. Before the training, a meeting washeld with the practice manager to discuss giving the prac-tice nurse(s) adequate time and support to carry outthe physical health checks once they had received thetraining.

To support the delivery of the health checks by thepractice nurse, the following additional preparatory workwas undertaken with a member of the administrativeteam:

• Checking that the SMI register was accurate to ensureevery patient is invited.

• Adjusting the physical health check computer templateto ensure it contained all the necessary parameters.

• Discussing possible systems of inviting appropriatepatients.

The training packageDeveloping the packageWe developed the Health Improvement Profile forPrimary Care (HIP-PC) (Hardy & Gray 2011) from theoriginal tool developed for secondary care (Hardy & Gray2010). This is a manual that provides practice nurseswith clear guidance and a rationale to help them makedecisions about individual patients. A website for practicenurses was constructed (now at http://physicalsmi.webeden.co.uk) as a repository for useful tools (e.g. letters,care-plans, scales, and HIP-PC), relevant information

260 S. HARDY


about SMI (e.g. medication, mental capacity act,schizophrenia, and bipolar disorder) and helpful links (e.g.leaflets, further information for health-care professionals,and charities).

Intended learning outcomesIntended learning outcomes for practice nurses were:

• Understand the definition of SMI• Know the signs and symptoms of SMI• Be familiar with the epidemiology of SMI• Be aware of the impact of SMI on physical health,

particularly the increased risk of CVD• Be confident in navigating and using the website• Be confident in carrying out a health check using the

HIP-PC manual as a guide• Be competent in entering data onto the computer

template• Feel confident in providing this role within their

practice• Liaise with relevant health-care professionals and

agencies.

TrainingA 2-hour foundation block of training was delivered at thepractice nurses’ usual place of work. To ensure the learn-ing outcomes were achieved, the training consisted ofgroup discussion and demonstration (carrying out a simu-lated health check). The link CMHW was invited toattend the training to increase the practice nurse’s moti-vation to work with them. It was our belief that learningtogether would help them to communicate with eachother.

Developing the questionnairesWe searched the literature to see if there were any vali-dated measures of attitudes to the physical health ofpeople with SMI and did not discover any. Therefore, wedecided to develop our own evaluation. Consultationswere carried out with practice nurses to develop thecontent of the questionnaires using an item pool createdby the author. This item pool was created from genuinestatements by practice nurses in discussions with theauthor over the previous year. To check the face validityof the questionnaires, they were reviewed by six practicenurses, four mental health nurses, and two academics,who gave feedback (e.g. one academic suggested includ-ing a question about the side effects of antipsychoticmedication). Questions pertaining to basic demographicdata were included (e.g. sex, ethnicity, and years of

experience as a registered nurse). The following threequestionnaires were used in the evaluation:

• Misconception questionnaire. This measures thenurses’ misconceptions of the physical health risksfactors associated with people with SMI. Ten mis-conceptions were presented for which participantsindicated whether they agreed or disagreed.

• Attitudes Questionnaire. This measures the nurses’attitudes towards providing physical health checks forpeople with SMI. Participants had the option to eitheragree or disagree with these beliefs.

• Motivation to work with CMHW Questionnaire. Thisaims to determine the practice nurses’ motivation toengage with their secondary care colleagues regardingpatients with SMI and any service developments.

Ethical approvalAs this project is a service evaluation it did not requireethical approval. Each participating practice gave writtenconsent. The nurses were not required to sign a consentform. They were given an information sheet making clearthat consent is implied by filling out the questionnaire,which is the usual practice for most surveys undertaken inthe UK.

RESULTS

Six GP practices agreed to take part. There was consider-able variation in the number of people with SMI regis-tered with each one. The mean number of patients was80 (range 13 to 123; standard deviation (SD) 45). Theaverage percentage of SMI patients as a proportion ofeach practice population was just under 1% (range: 0.3–1.89%; SD 0.56).

Practices identified a mean of 1.3 nurses (range: 1 to2); a total of eight nurses agreed to take part. They wereall white British females who, on average, had beenworking as a registered nurse for 23 years (range: 3 to 42).None of the nurses had any prior training in providingphysical health checks for people with SMI but one hadpreviously taken on the role.

The mean number of nurses answering correctly onthe misconception questions was two (SD = 3.17) pre-training and six (SD = 0.92) post-training (P = 0.00, con-fidence interval (CI) 0.41 (0.63 to 0.19), t = 3.93) (seeTable 1). This suggests that training had been effective inmodifying nurses’ misconceptions of SMI and physicalhealth; for example, they virtually all agreed that peoplewith SMI tended to die earlier and knew how to deal withsedation caused by antipsychotics.

PRACTICE NURSES AND SMI HEALTH CHECKS 261


The mean number of nurses answering correctly onthe attitude questions was five (SD = 1.55) pre-trainingand six (SD = 1.49) post-training (P = 0.50, CI 5.50(-0.85 to 11.85), t = 11.00) (see Table 2). Followingtraining, the practice nurses’ attitudes towards a numberof parameters were shifted in a positive direction; forexample, they nearly all believed that when they aredelivering a health check they can help patients withSMI identify triggers that cause worsening symptomsand that they can assist them to maintain activities thatare meaningful them.

The results from the motivation to work with CMHWquestionnaire revealed that practice nurses would bemuch more likely to be motivated to work with CMHWsregarding patients and service developments (seeTable 3).

DISCUSSION

It was disappointing that only six practices agreed totake part in the study. We tried to find out the reasonsfor non-participation by asking 120 GPs (from the 31

TABLE 1: The number of participants who disagreed with common misconceptions about physical health and serious mental illness (SMI) (n = 8)

Itemsn disagreed

beforen disagreed

after

1. People with mental illness die 5 years earlier than the general population (F) 0 72. Antipsychotic medication should be increased if the patient stops smoking (F) 0 63. Psychotic symptoms can be improved in schizophrenic patients by using caffeine (F) 7 64. If the patient is not under the care of the Community Mental Health team, then they do not need a care plan (F) 7 85. Patients who take lithium need their lithium levels monitored every 6 months and their creatinine and thyroid

levels measured every year (F)0 5

6. If the elevation of a patient’s prolactin levels is <2000 mIU/L, then it is reasonable to continue to monitor thelevel without any further action (F)

1 6

7. It is important to encourage all patients with severe mental illness to drink lots of fluid (F) 0 68. As a much smaller proportion of people with SMI are sexually active compared to the general population, they

are at less risk of acquiring a sexually transmitted infection (F)6 6

9. Cannabis use is a contributing factor in 50% of schizophrenia cases (F) 0 510. The side effect of sedation from taking an antipsychotic cannot be dealt with by the patient taking their

medication just before they go to bed (F)0 7

Mean disagreed (n, standard deviation) 2 (3.17) 6 (0.92)

TABLE 2: Trainee attitudes to the physical health of serious mental illness (SMI) patients (n = 8)

Itemsn disagreed

beforen disagreed

after

1. The diagnosis of a patient with severe mental illness affects whether recovery is possible (F) 7 72. You do not need to know the views of your patients with severe mental illness regarding their psychiatric

medications (F)6 8

3. You are not in a position to help your patients with severe mental illness identify people who can assist themduring a crisis (F)

6 7

4. You are not in a position to identify triggers that cause symptoms of your patients with severe mental illness toget worse and identify warning signs that come before they get symptoms (F)

6 8

5. It is sometimes necessary to disregard the patients’ preferences regarding their physical health to provide thebest treatment (F)

2 5

6. Many patients with severe mental illness cannot learn how to make well-informed choices about their physicalcare (F)

4 5

7. When providing patients with severe mental illness a health check, you should keep focused on their physicalhealth (F)

4 5

8. You should invalidate the patient’s goal when it is unrealistic (F) 3 69. A physical health check appointment does not need to include assisting patients with severe mental illness in

maintaining activities that are meaningful to them (F)5 8

10. The physical health goals of ‘normal’ people are often too stressful for patients with severe mental illness toreach (F)

5 4

Mean disagreed (n, standard deviation) 5 (1.55) 6 (1.49)

262 S. HARDY


practices invited) at a local training event to complete aquestionnaire. Only one person completed it, stating thatthey had not heard of the project. Therefore, we can onlyhypothesize as to why they chose not to participate: toobusy; no extra funding provided; no interest in SMI; feelproficient in providing care for this group already; thinktheir practice nurses should not be dealing with thisgroup; unaware of the project; or lack of faith in thetrainer.

The proportion of patients with SMI registered in eachpractice is slightly higher than the national average of0.8% (NHS Information Centre 2011). The variation inthe proportion of people with SMI registered with theparticipating practices might be explained by their loca-tion. The practices with a high population are located inthe town centre and those with the lower population arelocated in either a village or quiet suburb.

The aim of this study was to establish whether a train-ing package to address common misconceptions about thephysical health of people with SMI was effective in modi-fying practice nurses’ attitudes and increasing motivationto work with CMHW. This is the first time that anyonehas considered whether the misconceptions of practicenurses could be a barrier to providing physical healthchecks to people with SMI. Because training was effectivein correcting misconceptions, these practice nurses mightbe more motivated to carry out health checks in theirplace of work.

Practice nurses were not aware of the reduced lifeexpectancy of people with SMI. This is a possible expla-nation for why they have not seen screening these patientsfor CVD as part of their role. There are a number ofstudies that have been carried out in the UK that are

consistent with our observation that health checks are notbeing carried out routinely (Barnes et al. 2007; Robertset al. 2007). In addition, a systematic review of primarycare studies relating to somatic diseases in patients withschizophrenia revealed that health-care professionalsare not proactive in screening these patients (Oud &Meyboom-de Jong 2009).

A study in the UK determined that serious and endur-ing disorders, such as schizophrenia, made up 1.5% of thepatients seen by practice nurses and an estimated 2%were taking antipsychotic medication (Gray et al. 1999).This is without proactively inviting patients for a healthcheck. Before any change in their motivation to work withpatients with SMI can take place, practice nurses need tohave an understanding of the problem. This is highlightedin two models of behaviour change (Prochaska & DiClemente 1992; Rogers 1983). As a result, following train-ing, practice nurses might be more likely to offer screen-ing and appropriate interventions, either during a plannedhealth check or if the patient presents themselves foranother reason (e.g. helping them to manage the sideeffects of their medication, such as sedation).

We do not know if the attitudes of the participantsreflect those of other practice nurses. The fact that theywere asked by their employers to be involved in the studymight have had some influence. A study to determine theabilities of 24 practice nurses to detect psychiatric mor-bidity concluded that one reason for the variation in theirskills might be their interest in the subject (Plummer et al.2000). The attitudes of the nurses in this study were fairlypositive before training, and although there appeared tobe a small improvement after participation, we cannotclaim that this was due to our intervention.

TABLE 3: Practice nurse response to motivation to work with community mental health workers (CMHW) questionnaire

Practice nurse motivation to work with CMHWquestionnaire Number of nurses responding to each answer:

Question: Would you:Much more likely

(score 5)More likely

(score 4)Likely

(score 3)Less likely(score 2)

Don’t know(score 1)

Mean response(standard deviation)

Contact your own CMHW to inform them aboutchanges in health or circumstances of aparticular patient?

5 3 0 0 0 4.62 (0.52)

Contact your own CMHW to ask them about aparticular patient?

5 3 0 0 0 4.62 (0.52)

Contact your own CMHW to inform them aboutnew or changes in service developments?

4 3 0 0 1 4.12 (1.36)

Contact your own CMHW to ask them about newor changes in service developments?

4 3 0 0 1 4.12 (1.36)

Develop an individual system of communicationbetween your own CMHW

5 3 0 0 0 4.62 (0.52)

Overall mean response (standard deviation) 4.42 (0.27)



The results show that practice nurses in our studyalready had an awareness of the high chance of contract-ing a sexually transmitted infection in a proportion of thisgroup. This contrasts with mental health nurses whoappear to underestimate this risk (Hughes & Gray 2008).Our results highlight that the subject of sexual healthmight be less of a priority than some of the other issueswhen providing this programme to other practice nurses.

We discovered that following training, more practicenurses agreed that finding out the views of their patientswith SMI regarding their psychiatric medications wasimportant. This means they could be more likely toactively promote adherence (Gray et al. 2006). The resultsalso indicated that, despite a slightly lower mean scorerelating to the recovery of people with SMI, practicenurses showed a possibility that they might seek todevelop a therapeutic relationship with this group ofpatients. The scores were higher post-training for thequestions relating to discovering the patients’ views andpreferences and recognizing their own role in providingassistance with emotional or social issues. This demon-strates an acceptance to be supportive of the wellbeing ofthe client (Diorio 2001) and not exclusively follow achecklist of physical screening. This holistic approachembraces the process of recovery (Smith 2000).

After completing training, practice nurses revealedthat they would be much more likely to communicatewith their CMHW. This corresponds with a study to vali-date the readiness for interprofessional learning scale inthe postgraduate context (Reid et al. 2006), whichrevealed that most participants agreed that learning withother health-care workers would help them to communi-cate better with other professionals. In addition, becausethe whole concept of caring holistically for a patient withSMI is new to practice nurses, they might feel that theyare supported by having contact with CMHW. As veryfew community mental health teams have a clear strategyfor communication with primary care (Bindman et al.1997; England & Lester 2005), keeping up this contactmight be a challenge.

LIMITATIONS

There are several limitations in this study. It was designedfor a much larger group of participants and, therefore, theresults are not generalizable. Given the small numbersparticipating, a qualitative approach to data collectioncould have provided more meaningful results.

The answers for both the ‘misconception’ and ‘atti-tudes’ questionnaires are false. This could have hadan influence on the results if participants realized this

after the training and answered the questions as falseaccordingly.

Some of the statements in the misconception question-naire could have been confusing. In particular, in ques-tion one, we have stated that people with SMI die 5 yearsearlier as a false statement when in fact they do die earlierbut by 15–25 years.

The questionnaires were repeated directly after train-ing; therefore, it is possible that participants wouldremember the questions that were asked pre-training andthrough strategic learning remembered the answers byrote. To determine the durability of any improvements, alonger follow up is needed. In retrospect, this study couldhave been carried out electronically without the need tomeet with the nurses physically.

There is potential bias as the author (S.H.) deliveredand evaluated the intervention. We do not knowwhether the participants were typical or atypical practicenurses.

CONCLUSION

Practice nurses who complete the physical health checkfor severe mental illness training package have fewermisconceptions about SMI and might be more likelyto accept carrying out these health checks as part oftheir role; their motivation to work with the CMHW isenhanced.

FUTURE RESEARCH

By demonstrating that training might increase the moti-vation of practice nurses to carry out a physical healthcheck and work with CMHW, we have shown that itwould be feasible to carry out a much larger study, thefindings of which would inform educators in regardto developing relevant training for practice nurses, andboth commissioners and clinicians when planning caredelivery.

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