VOL: 101, ISSUE: 07, PAGE NO: 32
Darren Ward, MBA, BA, RGN, RMN, DipCPN, is deputy director of nursing, Central and North West London Mental Health NHS Trust
Research has confirmed that patients with mental health conditions suffer from high rates of physical illness, much of which goes undetected. In addition, studies of cohorts of patients with schizophrenia consistently show higher levels of natural and unnatural mortality than the general population (Brown et al, 2000). Reasons for these higher natural mortality rates include unrecognised medical disease, unhealthy lifestyles and substance abuse. A number of lifestyle factors make patients with mental health conditions more vulnerable to poor physical health: they tend to have poorer diets, smoke more and take less exercise. Mortality rates from smoking-related disease among people with schizophrenia are higher than in the general population (Phelan, et al 2001).
McCreadie (2003) describes the lifestyle habits of people with schizophrenia, noting poor dietary choices, with smokers eating less fruit and vegetables than non-smokers. The majority of patients in the study also had raised serum cholesterol levels. Faulkner et al (2003) also note that the proportion of people with schizophrenia who are overweight ranges from 40 to 62 per cent, which is almost four times as high as rates in the general population.
The National Service Framework for Mental Health (Department of Health, 1999) states that people with a mental illness should have their physical health needs assessed. However, the assessment and delivery of physical health care in mental health service settings is patchy and far from ideal. Many mental health staff lack the appropriate training and skills to deliver good levels of physical health monitoring.
Weight gain and type 2 diabetes are worrying issues for patients with mental health conditions. Evidence from trials suggests that certain drugs, particularly the new atypical anti-psychotics clozapine and olanzapine, can cause weight gain, which may also result in a higher incidence of type 2 diabetes (Allison et al, 1999).
As part of the Commission for Health Improvement programme at Central and North West London Mental Health NHS Trust, the team has developed a small department of physical health care. The department is headed by the deputy director of nursing who is a dual-trained nurse, and it consists of two general nurse practitioners (one of whom specialises in tissue viability and the other venepuncture), a resuscitation officer who is a trained paramedic, and the trust’s infection control nurse.
The new department carried out a trust-wide audit to establish a physical health care baseline. The audit was based on a questionnaire for both nurses and doctors to ascertain their confidence in giving physical assessments and treatment, and a trust-wide audit of case files.
Key findings from the trust audit
Questionnaires were returned by 153 nurses and 21 doctors (Box 1). Cardiopulmonary resuscitation was identified by nurses and junior doctors as an area where they needed more training to raise confidence levels - 56 per cent of nurses and more than 70 per cent of junior doctors felt they required more training in basic life support. Half of the nurses felt that they needed more training in diabetes management to increase their confidence levels. More than half of the junior doctors believed that patients’ physical care needs were not given enough attention. Some 43 per cent of junior doctors were not confident about the level of physical health care skills of mental health nurses.
Physical nursing assessments were missing in more than half of the case files that were audited. The majority of care plans did not reflect physical care needs. In 97 per cent of case files there was no evidence of a physical exercise plan or use of local gym or leisure facilities. In more than 90 per cent of cases there was no evidence of diabetes advice or support. Smoking and alcohol habits were not recorded in patients’ notes in about 70 per cent of cases (Box 2).
The newly formed department of physical health care is using the local audit data that have been gathered to focus and target its training plans for RMNs and doctors over the next year.
The department has introduced a new standardised physical health assessment tool for nurses and a physical examination form for doctors. It is hoped that picking up physical illness early will enable a quicker referral and better access to general medical services and therefore a reduction in morbidity.
In its first year, the department will focus its attention on inpatient services. A number of link nurses from inpatient units have been identified to provide a satellite structure to the central department. The link nurses identified have been given two days of training in aspects of physical health care, both in theoretical and practical skills-based techniques.
We plan to roll out this training package across the trust for RMNs and doctors. The link nurses will spread learning at ward level and monitor the use of physical assessment and examination forms. They will also carry out small audits at the level of their local ward or unit.
The department will continue to meet the link nurses at regular intervals to help keep them up to date with developments and also to find out from them what problems there are at ward level.
All nursing and medical staff across the trust will be offered training in basic life support skills, with annual training updates provided. We plan to train all the link nurses who have been identified up to an intermediate level of life support and train smaller numbers in advanced life support. The resuscitation officer will aim to standardise resuscitation equipment on units across the trust, ensuring that staff are all able to use the equipment properly.
There will be training in all aspects of tissue viability, not only pressure area care and wound management, but also the importance of good nutrition. There will also be venepuncture training for nurses to enable units to reduce their reliance on phlebotomy services at local general hospitals.
The department has devised a set of simple clinical practice guides for various assessment and treatment procedures. These guides will be kept on individual wards. It is hoped that these simple, practical guides will be of benefit to nurses ‘on the spot’, freeing them of the need to trawl through lengthy policy and procedure documents.
Plans for the future
There are now a number of ‘well-being’ support programmes across the UK that help patients with weight management and healthy living, although most of these are based in the community. The department of physical health care hopes to develop the role of link nurses to allow them to start such programmes while patients are in hospital. We will of course need to identify interested colleagues in the community who can maintain and monitor the programmes once the patients have left the hospital.
As well as providing training programmes to nurses and doctors, the department is available during normal working hours for advice and consultancy on any aspect of physical ill health.
In 12 months’ time the trust intends to carry out a repeat audit, using the same approach as before, to gauge what progress has been made.
- This article has been double-blind peer-reviewed.
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