VOL: 103, ISSUE: 38, PAGE NO: 28-29
Donna Eldridge, RMN, BSc; Andrew Dickers, RMN, MA, PGCLT
Donna Eldridge is assistant director of nursing, Kent and Medway NHS and Social Care Partnership Trust; Andrew Dickers is lead nurse, Kent and Medway NHS and Social Care Partnership Trust.
Eldridge, D., Dickers, A. (2007) A physical well-being service for mental health clients. www.nursingtimes.net …
Abstract Eldridge, D., Dickers, A. (2007) A physical well-being service for mental health clients. www.nursingtimes.net This article describes the development of a physical well-being service for clients with a mental health problem. It explores the strategy for developing the service, training, staff support mechanisms and the establishment of a steering group. Nurses who have been involved in the project have observed a good response from clients, and a trial of the service in one area has resulted in improvements in clients’ physical health. IntroductionMental health nursing has faced many challenges over recent years such as the closures of the large institutions and the introduction of the care programme approach (CPA). It has also developed significantly, with new ways of working, such as nurses undertaking more psychological therapies. Therefore it is inevitable that some fundamental nursing activities are lost along the way. One of these activities is the monitoring of clients’ physical health needs, especially of those with a severe mental illness (SMI). This article highlights the need for increased input into the identification and delivery of physical well-being initiatives for patients with serious mental illness. In Kent what started as a one-nurse service soon became a Kent-wide initiative that has started seeing the development of mental health nursing practices. It has expanded the remit of services by offering physical well-being assessment, treatment and education, resulting in positive improvements in clients’ physical health. The work and role of physical well-being professionals, the development of the service and its implementation across Kent are discussed, as well as the difficulties of changing practice in an ever-changing NHS. BackgroundThe Department of Health’s (2004) white paper Choosing Health: Making Healthy Choices Easier recommended that the physical health and well-being of people with a mental health problem must be improved, as those with an SMI are three times more likely to die prematurely than those without (Harris and Barraclough, 1998). Suicide is a factor but death can also occur because of respiratory and other diseases. Our clients with SMI are also known to have a poor diet, which can lead to obesity and diabetes. Other factors are smoking, increased use of alcohol and some illicit drug-taking. In addition, our clients with SMI sometimes find it difficult to engage with primary care services, which results in them not accessing routine health checks. The chief nursing officer’s (CNO) review of mental health nursing (DH, 2006) supported the improvement of physical health and well-being of individuals with SMI. A key recommendation from the review is that mental health nurses should focus on the wider needs of the client, using their skills to improve physical well-being through better assessment and health promotion activities, and by providing more psychological therapies. NICE (2002) published guidelines on the treatment and management of schizophrenia in primary and secondary care. These guidelines made a range of recommendations to improve physical health, such as reviewing and monitoring medication with regard to unwanted side-effects, physical assessment and physical health checks. The guidance also clarified the role of both primary and secondary care in meeting the recommendations and highlighted the importance of shared responsibility and regular communication between both services. Mental health clients have complained that, in general, insufficient attention is paid to their physical health (Rethink, 2002). The physical well-being support programme began as a pilot initiative in February 2003 through a partnership between Eli Lilly and Company, Inventive Solutions training services and eight mental health trusts across the UK. Within the pilot the following data was collated (see below). Some 966 patients enrolled and 80% completed the two-year pilot. Box1
|Baseline||End of pilot outcomes||Significance P value|
|Proportion of patients withhealth checks||31%||100%|
|BMI||31%||31%30.8% gained weight26.8% weight neutral42.4% lost weight|
|Alcohol results(% teetotal)||65.1%||73.2%||P<0.01|
|No regular exercise||37.4%||12.4%||P<0.0001|
|Random blood glucose >7.1mmol/L||12.4%||Not presented|
(Source: Eli Lilly and Company, June 2006). Data from Bushe and Holt (2004) showed that clients with a diagnosis of schizophrenia had a 2-4 times higher rate of diabetes than the general population, and clients with bipolar affective disorder had a 2-3 times higher rate than the general population. Diabetes UK (2006) recommended, in its early identification position statement, that there should be regular screening for type 2 diabetes in the population. Developing the physical well-being service inKentIn 2006 two mental health trusts within Kent merged, forming the Kent and Medway NHS and Social Care Partnership Trust. The trust covers a population of approximately 1.6 million and has around 4,000 members of staff from all disciplines. The trust provides mental health services across the county of Kent and in Medway, and services for people with learning disabilities in the west of the county and in East Sussex. Within the former East Kent Partnership Trust, community mental health nurse Karen Healy took part in an 18-month secondment to Inventive Solutions as part of the pilot. Ms Healy delivered the well-being support service, offering physical health, medication management and lifestyle assessments to clients with SMI in the trust’s Thanet area. Clients were given a minimum of four one-to-one consultations and immediate access to physical activity groups that she had set up in the local community. The data confirmed our initial thoughts but was not surprising. Of the 184 clients enrolled:
- The majority (77%) had a BMI over 25 (overweight or obese);
- Nearly half (48%) had a BMI over 30 (obese);
- Some 71% were hypertensive.
Following blood screening the results showed:
- Some 18% had raised prolactin;
- One-fifth (20%) had raised blood glucose;
- Over half (54%) had raised cholesterol.
All clients were then followed up and abnormal results addressed. By the end of the secondment:
- Over a third (36%) had managed to significantly increase their physical activity levels;
- Some 40% had reduced their alcohol intake;
- Nearly a third (27%) had reduced the amount they smoked and 11% had stopped smoking;
- Some 23% participated in healthy living groups;
- Non-attendance rates were only 12%.
Ms Healy reported that the clients had thoroughly enjoyed this holistic approach to their care and had fully participated in recommended changes to their lifestyles. They had felt more involved in their care and, consequently, took more responsibility for their mental and physical well-being. Following a European conference held by Eli Lilly and Company, the trust was given a substantial number of free training places for the implementation of the service, although it became apparent that the initiative was not just about training staff to deliver the service. There was a bigger issue of the change in practice for nurses. Regardless of their specialty, nurses continually have more and more work placed on them without dedicated time given to their tasks. If the implementation was to be successful for the service, it could not be seen as another ‘add-on’ to their roles. Some questions that needed to be answered were:
- How to embed this initiative in practice;
- How to engage with primary care services;
- How to secure professionals’ commitment;
- How to evaluate the success of the service;
- How to overcome some of the suspicion around working with the pharmaceutical industry.
With the data that was available, there was no doubt that the project would be successful. The trust fully supported it without concern. StrategyBefore the training commenced, there had to be an agreement with the trust’s executive management team about its implementation. At the time, the trust did not have a policy on physical health and it was evident that such a policy would support the service. Agreement also had to be obtained from operational directors/managers to ensure that the staff who were trained had one day a week of protected time to implement the service. At the initial stages, it was felt that it would be a risk to the service if this was not agreed. There was no surprise that the majority of professionals within the trust agreed that the service should be implemented. Agreement was obtained for ringfenced time and the training programme started at the end of September 2006. TrainingThe training consisted of a three-day programme, which was provided by Inventive Solutions and sponsored by Eli Lilly and Company.It comprised:
- How to set up a physical well-being service locally;
- The process of carrying out physical health checks,
- Monitoring side-effects of treatment;
- How to run a healthy living group;
- How to set up and run a physical activity group;
- How to offer appropriate lifestyle advice.
The trust initially decided to make the training four days with the inclusion of phlebotomy training, which would enable staff to deliver the service more or less immediately. Through Inventive Solutions, the training programme has RCN accreditation. The staff who received training worked in inpatient services, community/crisis resolution team settings or rehabilitation services. To date there are 72 nurses/occupational therapists who have been trained across the trust, with many more waiting to undertake the training. To provide further understanding of the physical well-being service, monthly awareness sessions were set up for staff across the whole organisation. The aim was to promote the role of the well-being professional and the services offered, and also to recruit staff to be trained within the locations. The serviceThe overall aim of the physical well-being service is to improve lifestyle and reduce physical ill-health in clients with SMI. Once trained, all nurses and occupational therapists set up consultations with either the clients in their caseload or clients within their team who have been referred by their care coordinator. These consultations assess physical health needs and identify areas that patients would like to address and work towards improving. This is done through physical health observations such as blood pressure, weight, blood tests to check and monitor for diabetes, prolactin and cholesterol levels and also the assessment of BMI. In addition clients participate in healthy living groups and physical activity groups. The physical well-being support service has three components:
- A one-to-one consultation by a nurse/occupational therapist who carries out a complete health check and reviews lifestyle and side-effect management;
- Referrals to other NHS agencies when health issues are Identified requiring specialist intervention;
- Access to healthy living groups (for weight management advice, for example) and physical activity groups.
Physical activity groupsThe client would be invited to join a physical activity group. This group may do a variety of activities and may include walking, swimming, chair exercises or the use of a gym. These activities are dependent on the ability of the client and the availability within the local area. Healthy living groupsClients are invited to attend a healthy living group, which will look at weight management and a healthier lifestyle; this can include stop smoking groups. Staff support mechanismsTo support the professionals trained for the physical well-being service, regular six-weekly link meetings were set up to discuss and share how their practice was developing. It was also an opportunity to problem solve. These meetings are led by the physical well-being clinical nurse specialist and the lead nurses for the trust. In addition, some areas in the workplace settings had designated specific clinical areas for the service and some staff were given computers by the IT&M directorate, which supports the data collection activity. The steering groupAs the service was developing across the organisation, a steering group was established to monitor and develop the service as it gained momentum. The steering group’s aims were to ensure that the service was sustained within the trust and to support staff in its implementation. The membership of the steering group is from a broad range of professional groups, as follows:
- Assistant director of nursing;
- Lead nurses;
- Well-being support nurse specialist;
- Hotel services;
- Local universities;
- Clinical governance/audit department;
- Social care;
- Chief pharmacist;
- Health promotion;
- Care Services Improvement Partnership;
- PCT commissioner;
- Consultant psychiatrist;
- Modern matron;
- Occupational therapy;
- Learning and development.
The steering group meets on a monthly basis and has developed some key themes for action:
|Evaluation and audit(baseline)(Mapping existing services)|
|Future funding issues|
It is pleasing to report that all but a few of the key themes have now been achieved. The trust worked in partnership with the University of Greenwich, which has now developed a CPD module at degree level in physical well-being and mental health; it is due to start in late September/early October and will cover two semesters. It is envisaged that the majority of trust staff who have undertaken the training in the trust will attend the module. Challenges to implementationIt is important to acknowledge that there have been some challenges in implementation. At the initial stages, although agreement for the ringfenced time was given by the executive management team and operational directors, agreement was not successful in all areas from middle managers. This has caused some staff to feel frustrated as they have not been able to implement the service. In addition, as part of the training staff are taught how to input data into a web-based audit tool. Each site has its own web page to measure programme progress, epidemiological data, key data on physical health and lifestyle indicators, measurement of interventions, and reports that support the achievement of targets. Unfortunately, some staff find it difficult to either find the time or forget how to input, resulting in some data remaining paper based and slowing down the evaluation of the service. Another challenge was to overcome suspicion from both internal and external stakeholders of having a pharmaceutical company’s input. The training programme has never been product-related and Eli Lilly has been extremely supportive and provided the drive for the development of the service within the trust. Data collectionAs mentioned above, there is a web-based audit tool that collects the data on the service. This information is entered by either the nurse or the occupational therapist. To date, the service has picked up three new cases of type 2 diabetes. Some 34% of the clients enrolled have a BMI over 25 and 24% have a BMI over 30. Practitioners’ experiencesLastly, it is important to hear from the practitioners who are delivering the service. Peter Teuma, RGN, RNMH, WBS nurse‘As you can see I am quite proud of my title because it was not too long after qualifying in adult nursing that I realised that I would like to follow a career path in mental health nursing.’I have a great empathy for individuals with enduring mental health needs. Following my mental health nurse training, my long-standing holistic view of helping people to achieve recovery from being unwell in any way has been strengthened.’The WBS provides me with an excellent platform from which to achieve this and I look forward to implementing this invaluable tool for the benefit of my clients.’Ellie Whitworth, occupational therapist‘I have been working with well-being and support trained nurses who have taken on the role of registration and I have taken on the design and co-running of a health and well-being group. This is the initial plan, developed by the staff including myself, who attended the training, which so far has been working well. Initially I designed a structured group programme which, due to the client group and the high turnover of patients, I have had to modify.’However the material developed has been very useful and I have found a more informal way of working which has been very successful. The group is open and takes an interactive discussion format. From this, we develop practical ways in which we can develop a healthierlifestyle. In fact we are cooking a healthy fry-up this week (grilling not frying, including lots of vegetables and fresh fruit).’This was an idea developed in the group predominantly by service users with little prompting from the group facilitators, and led to a long discussion about diet and how foods can be prepared in a healthier way. The group had a really good atmosphere - people were laughing and joking and engaged proactively in the session. In fact the group have even caught me in the week and reminded me about this week’s session.’I have been letting the clients take the lead in identifying the topics they feel are important under the umbrella of health and well-being and have developed sessions based on these.’Initially I was concerned that health and well-being would be training I had gone on early on in my post and would fall by the wayside or I would not know how to implement, particularly in this setting.’However, fellow staff [who] went on the training and the link meetings have meant this has not been the case, which I am pleased about as running the group and working with others getting the project off the ground has been really enjoyable.’Lorraine Trainor, RMN‘[With] regards to the well-being, I feel that it has got a lot of people looking more holistically at their clients and not making presumptions that they are having their physical needs met by their GP.’It has flagged up a massive deficit within our clients who are on the enhanced level of CPA, with some having no physical interventions for a number of years. For example, a lady I assessed hadn’t had a smear test for 20 years. I could go on but I won’t.’I will, however, say that my successes - if you can call them that - are that I have identified several people who have high blood sugars, hypertension, obesity, polypharmacy and sexual health problems, all of which I have been able to refer on to appropriate services. Also I have been able to coordinate several groups addressing ways of dealing [with]/managing problems identified.’Marion Saumtally,community mental health nurse/lead nurse in psychosocial interventions (PSI)‘I have discovered through having a focused discussion with clients about their physical well-being - in particular aspects of their lifestyle which may not have been addressed before with them, for example, diet and exercise - how this can facilitate the take-up of resources that they may not have considered previously.’These include services provided by their GP, Weight Watchers and gym membership. Clients can bring about changes for themselves by setting goals, for example, by walking more etc to promote their own sense of well-being.’I have welcomed the programme as it recognises the need to provide health promotion activity to a client group where this can be overlooked, falling between the services of secondary and primary care. I think the programme will help to strengthen these relationships. It endorses client collaboration.’I have found listening to others about their experience useful. It provides a way of facilitating social inclusion for clients who have severe and enduring mental illness in an area where research exists to say that this population are more at risk of dying earlier.’Marty Trainor, crisis resolution and home treatment team1. ‘Implementation:This have been quite slow and I think it is due to changing or trying to change colleagues’ perception to take on something different; in a positive way this makes my trying more interesting.2. My success up to now is:(a)The acceptance of my well-being assessment tool by the majority of the team members;(b)Close working that I have with well-being advisers in other teams and the ongoing work that has happened;(c)Agreement of my manager and consultant to work with me on this project, they both can see the logic of the system;(d)I have achieved my phlebotomy training and I am now recognised.ConclusionThe physical well-being service has proved to be a valued role for nurses and occupational therapists and has especially brought the nurses’ role back into focus. It is important to recognise that the essence of the service is about maximising the opportunities of working with clients and enabling them to consider their choices around lifestyle. It is therefore anticipated that the development of the physical well-being service within the trust will: meet the needs of service users and improve their chances of success; help retain staff through the development of a new role with high job satisfaction; and meet the challenges set out in the CNO’s (DH, 2006) review of mental health nursing and the recommendations in Choosing Health: Making Healthy Choices Easier (DH, 2004). The service has also helped to meet the NICE guidelines on the treatment and management of schizophrenia. Other trusts may be considering within their clinical governance committees how they can implement this NICE guidance - perhaps developing a physical well-being service may be the answer. Because of the service’s success, it has now been rolled out to other directorates in mental health such as older adult services, learning disabilities and child and adolescent mental health services. In addition, a further training programme is being developed within the trust for unqualified staff in relation to helping with some of the physical health assessments and running social and physical activity groups. ReferencesBushe, C., Holt, R.(2004)Prevalence of diabetes and impaired glucose tolerance in patients with schizophrenia. British Journal of Psychiatry; 184: Suppl 47, 567-71. Department of Health (2006) From Values to Action: The Chief Nursing Officer’s Review of Mental Health Nursing. London: DH.
Department of Health(2004) Choosing Health: Making Healthy Choices Easier. London: DH. Diabetes UK (2006) Early identification of people with type 2 diabetes. Position Statement. London: Diabetes UK. Harris, E.C., Barraclough, B. (1998) Excess mortality of mental disorder.The British Journal of Psychiatry; 173: 11-53. NICE (2002) Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. London: NICE. Rethink (2002) Doesn’t It Make You Sick? Side-effects of Medicines and Physical Health Concerns of People with Severe Mental Illness. London: Rethink (registered as the National Schizophrenia Fellowship). www.rethink.orgSource for data in Box 1: Eli Lilly and Company Limited (2006) Basingstoke, Hampshire. Policy documents underpinning this projectCare Services Improvement Partnership (2006) 10 High Impact Changes for Mental Health Services. Colchester: CSIP. Department of Health (2006) Choosing Health: Supporting the Physical Needs of People with Severe Mental Illness: Commissioning Framework. London: DH. Department of Health(2006) From Values to Action: The Chief Nursing Officer’s Review of Mental Health Nursing. London: DH. Department of Health (1999) National Service Framework for Mental Health: Modern Standards and Service Models. London: DH. Disability Rights Commission (2006) Equal Treatment: Closing the Gap. Stratford-upon-Avon: DRC. NICE (2002) Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. London: NICE. Revised general medical services (GMS) contract http://www.nhsemployers.orghttp://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Primarycare/Primarycarecontracting/GMS/DH_4125638AcknowledgmentsPeter Hasler, director of nursing and modernisation, Kent and Medway NHS and Social Care Partnership Trust Mark McEwen, Inventive Solutions Arlene De Souza, Eli Lilly and Company Operational directors/associate directors, Kent and Medway NHS and Social Care Partnership Trust