Embed Size (px)
Citation preview
RESEARCH ARTICLE Open Access
Mental health nurses’ attitudes, experience,and knowledge regarding routine physicalhealthcare: systematic, integrative review ofstudies involving 7,549 nurses working inmental health settingsGeoffrey L. Dickens1,2* , Robin Ion3, Cheryl Waters1, Evan Atlantis1 and Bronwyn Everett1
Abstract
Background: There has been a recent growth in research addressing mental health nurses’ routine physicalhealthcare knowledge and attitudes. We aimed to systematically review the empirical evidence about i) mentalhealth nurses’ knowledge, attitudes, and experiences of physical healthcare for mental health patients, and ii) theeffectiveness of any interventions to improve these aspects of their work.
Methods: Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple electronic databases were searched using comprehensive terms. Inclusion criteria:English language papers recounting empirical studies about: i) mental health nurses’ routine physical healthcare-related knowledge, skills, experience, attitudes, or training needs; and ii) the effectiveness of interventions toimprove any outcome related to mental health nurses’ delivery of routine physical health care for mental healthpatients. Effect sizes from intervention studies were extracted or calculated where there was sufficientinformation. An integrative, narrative synthesis of study findings was conducted.
Results: Fifty-one papers covering studies from 41 unique samples including 7549 mental health nurses in 14countries met inclusion criteria. Forty-two (82.4%) papers were published since 2010. Eleven were intervention studies;40 were cross-sectional. Observational and qualitative studies were generally of good quality and establish a baselinepicture of the issue. Intervention studies were prone to bias due to lack of randomisation and control groups butproduced some large effect sizes for targeted education innovations. Comparisons of international data from studiesusing the Physical Health Attitudes Scale for Mental Health Nursing revealed differences across the world which mayhave implications for different models of student nurse preparation.
(Continued on next page)
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: [email protected] Mental Health Nursing, Centre for Applied Nursing Research(CANR), Western Sydney University, Sydney, Australia2South West Sydney Local Health District, Sydney, AustraliaFull list of author information is available at the end of the article
Dickens et al. BMC Nursing (2019) 18:16 https://doi.org/10.1186/s12912-019-0339-x
(Continued from previous page)
Conclusions: Mental health nurses’ ability and increasing enthusiasm for routine physical healthcare has beenhighlighted in recent years. Contemporary literature provides a base for future research which must now concentrateon determining the effectiveness of nurse preparation for providing physical health care for people with mentaldisorder, determining the appropriate content for such preparation, and evaluating the effectiveness both in terms ofnurse and patient- related outcomes. At the same time, developments are needed which are congruent with theneeds and wants of patients.
Keywords: Mental health nurses, Emergency medicine, Deteriorating patient, Educational interventions, Attitudes,Knowledge
BackgroundPeople with a mental disorder diagnosis are at morethan double the risk of all-cause mortality than the gen-eral population. Most at risk are those with psychosis,mood disorder and anxiety diagnoses. Median length oflife lost by this group is 10.1 years greater for peoplewith a diagnosis of mental disorder than for generalpopulation controls, but mortality rates are significantlyhigher in studies which include inpatients [1]. While riskof unnatural causes of death, notably suicide, are greatlyincreased in this group, it is death from natural causesthat remains responsible for the vast majority of mortal-ity. In people with schizophrenia, for example, cardio-vascular disease accounts for about one third of alldeaths and cancer for one in six, while other commoncauses are diabetes mellitus, COPD, influenza, andpneumonia [2]. A relatively high rate of tobacco smokingin this group is implicated in significant increased mor-tality [3], as is obesity [4], exposure to high levels of anti-psychotic pharmacological treatment [5], and mentaldisorder itself [1].Accordingly, the physical health of patients with men-
tal disorder has been prioritised, becoming the focus ofguidelines for practitioners in general [6] and for mentalhealth nurses and other clinical professionals specifically[7–9]. However, while policies and guidelines are neces-sary prerequisites of change they must also be imple-mented in practice if they are to have a positive effect;one of the key barriers to change implementation formental health nurses has been identified as lack of confi-dence, skills, and knowledge [10]. Robson and Haddad([11]: p.74) identified that surprisingly ‘modest attention’had been paid to the issue of such attitudes and know-ledge among nurses related to their role in physicalhealth care provision, and developed the Physical HealthAssessment Scale for mental health nurses (PHASe) inorder to further investigate the phenomenon. Since then,there has been a tangible and growing response amongmental health nursing academics and practitioners. Inrecent years, published literature reviews have covered adecade of UK-only research on the role of mental health
nurses in physical health care [12], patients’ and profes-sionals’ perceptions of barriers to physical health carefor people with serious mental illness [13], the focus andcontent of nurse-provided physical healthcare for mentalhealth patients [14], and the physical health of peoplewith severe mental illness [15]. There has also been anupsurge in the amount of related empirical research.However, to date, no one has systematically reviewedthis growing literature about mental health nurses’ atti-tudes towards, or their related knowledge and experi-ence about providing routine physical healthcare.Further, studies about the effectiveness of interventionsdesigned to improve their delivery of or attitudes to rou-tine physical healthcare have not been systematically ap-praised. This is surprising given the known linksbetween nurses’ attitudes and their implementation ofevidence-based practice [16–18] and the centrality ofmeasuring nurses’ attitudes to physical health caredelivery in recent mental health nursing research on thetopic [11, 19, 20].In this context we have conducted a systematic review
to identify, appraise, and synthesise existing evidencefrom empirical research literature about i) mental healthnurses’ experience of providing physical healthcare forpatients and about their related knowledge, skills, educa-tional preparation, and attitudes; ii) the effectiveness ofany interventions aimed at improving or changing men-tal health nurse-related outcomes; and iii) to identify im-plications for the future provision of relevant trainingand education, for policy, research, and practice. Thespecific review question being addressed therefore is: whatis known from the international, English language,empirical literature about mental health nurses’ skills,knowledge, attitudes, and experiences regarding provisionof physical healthcare.
MethodsDesignA systematic review of the literature following the rele-vant points of the Preferred Reporting Items for System-atic Reviews and Meta-Analyses [21].
Dickens et al. BMC Nursing (2019) 18:16 Page 2 of 21
Search strategySince the review scope encompassed questions about ex-perience and effectiveness a dual literature search strat-egy was developed. For studies about mental healthnurses’ experience of delivering physical healthcare aPopulation Exposure Outcome (PEO) format reviewquestion was developed (Population: mental healthnurses; Exposure: physical healthcare provision forpatients or related training; Outcomes: experiential, so-cial, educational, knowledge, or attitudinal terms, seeAdditional file 1: Table S1). For studies of the effective-ness of interventions to improve or change mentalhealth nurse-related outcomes a Population InterventionComparator Outcome (PICO) structure was imple-mented (Population: mental health nurses; Intervention:any intervention including physical health-related educa-tion, policy or guideline change; Comparator: any ornone; Outcome: any) [22]. We searched five electronicdatabases: i) CINAHL, ii) PubMed, iii) MedLine, iv)Scopus, and v) ProQuest Dissertations and Theses usingtext words and MeSH terms. The references list of all in-cluded studies, together with those of relevant literaturereviews, and the tables of contents of selected mentalhealth nursing journals were hand searched. The searchterms were informed by previous literature reviews onthe subject of physical healthcare in mental health. Theinitial search was conducted in April 2018 and re-run inSeptember 2018.
Inclusion and exclusion criteriaInclusion criteria for studies were English language ac-counts of empirical research which investigated mentalhealth nurses’ experience of providing physical healthcare or examined the effectiveness of any interventionthat aimed to improve outcomes related to the provisionof physical healthcare. Thus, studies of interventionsaimed at changing nursing practice, behaviour, know-ledge, attitudes, or experiences were eligible, but notthose which solely attempted to determine the effect ofan intervention on nurses in terms of patient outcomes.While improvement in patient care and outcomes isclearly the desirable endpoint of any intervention onnurses, previous reviews have indicated that no goodquality studies exist [23]. Additionally, studies were onlyeligible for inclusion where the practitioners involvedcomprised or included mental health or psychiatricnurses or mental health nursing students, or registerednurses whose practice was within mental health services.Included studies could have used any design or meth-odological approach. As in previous reviews, studiessolely about mental health nurses providing care forpeople with alcohol/ drug misuse, or mental disorder/substance misuse dual diagnosis were not eligible. Stud-ies about mental health nurses and the provision of
emergency physical care or of their experience of provid-ing care for the seriously deteriorating physical health ofa patient were omitted as this is the subject of a separatereview (Dickens et al. submitted).
Data extractionInformation about the study title, author, publicationyear, data collection years, location (country), researchobjectives, aims or hypotheses, design, population,sample details and size, data sources, study variables (i.e.details of intervention) or other exposure, unit ofanalysis, and study findings were extracted from full textpapers. Corresponding authors of included studies werecontacted regarding any issues where clarification oradditional data could aid the review.Studies were categorised as interventional or observa-
tional. Intervention studies investigated the impact of aneducational, policy, or practice intervention in terms of anymental health nurse- or nursing- related outcome, e.g.,knowledge, attitudes, behaviour. Intervention studies werefurther sub-classified as simulation studies (as defined byBland et al. ([24]: p.668) “a dynamic process involving thecreation of a hypothetical opportunity that incorporates anauthentic representation of reality, facilitates active studentengagement and integrates the complexities of practicaland theoretical learning with opportunity for repetition,feedback, evaluation and reflection”), traditional educationalinterventions (e.g., lectures, workshops, workbooks), orpolicy-level interventions (e.g., requiring nurses to followsome new policy or implement some new practice). Obser-vational studies either described mental health nurse- ornursing- related outcomes and/or utilised case controldesigns to compare them with those of other occupationalor professional groups and/or used qualitative methods.
Study quality appraisalThe likelihood of bias in intervention studies wasassessed against criteria described by Thomas et al. [25]and encompassed assessment of the likelihood of selec-tion bias in the obtained sample, study design, potentialconfounders, blinding, potential for bias in data collec-tion from invalid instrumentation, and participant reten-tion (see Additional file 2: Table S2). Relevant itemsfrom the US Department of Health & Human SciencesNIH Quality Assessment Tool for Observational Cohortand Cross-Sectional Studies [26] were used to assesscross-sectional observational studies (see Additional file 3:Table S3). Qualitative descriptive studies were assessedusing the Critical Appraisal Skills Programme [27] tool(See Additional file 4: Table S4). Multiple papers arisingfrom single studies were quality assessed as a single en-tity. Study quality was initially undertaken independentlyby at least two of the team. A good level of inter-rateragreement was achieved (Cohen’s Kappa = 0.742 between
Dickens et al. BMC Nursing (2019) 18:16 Page 3 of 21
pairs of raters). Disputed items were discussed by GDand CW and consensus achieved.
Study synthesisThe available total and subscale data from those studiesthat conducted data collection via the Physical Health-care Attitude Scale for mental health nurses (PHASe[11]), the only scale used across more than two studies,was tabulated and compared across studies using un-paired t-tests in QuickCalcs GraphPad software. Whereindividual item mean and dispersion scores were un-available estimates were calculated as follows: the meanmean (i.e., Σ means / n means) and the estimated stand-ard deviation (the square root of the average of the vari-ances [28]). Also, and where available, dichotomised data(‘Strongly agree’ or ‘agree’ responses versus all other re-sponses) from the multiple studies using the 14-itemPHASe scale investigating self-reported current involve-ment in aspects of physical healthcare was tabulated andsubjected to Chi-squared analysis. Significant cross-studydifferences of means and proportions involved all subscaleor item data for each study being compared with the
corresponding subscale or item from the original studydevelopment sample, ‘the reference group’ [11].Where available, effect sizes for correlational, interven-
tional, or difference-related outcomes from studies wereextracted or, where sufficient information presented,calculated. Where sufficient information was not pre-sented we attempted to contact the corresponding au-thor for clarification. Appropriate effect size statisticswere calculated using an online resource [29]. All otherinformation from study results was subject to a qualita-tive synthesis conducted by author 1 and subsequentlyrefined and agreed by all of the authors.
ResultsStudy settings and participantsThe search strategy resulted in the inclusion of 41 studysamples published in 51 papers (see Fig. 1) involving7549 (M[SD] = 200.5[374.1], Mdn = 47, range 2 to 1899)mental health nurses and n = 213 mental health nursingstudents (Mdn = 33). Thirty-three samples included onlynurses, of which 20 drew specifically on mental healthnurses or nurses working in mental health settings only;
Fig. 1 PRISMA study inclusion flowchart
Dickens et al. BMC Nursing (2019) 18:16 Page 4 of 21
eight samples were multidisciplinary. Four papers drewon two samples (i.e., two papers per study) while onesample featured in nine separate papers [30–38]. Studieswere conducted in the UK (k = 17), Australia (k = 9), US(k = 4), Canada (k = 2), Qatar, Hong Kong, Japan, Jordan,Belgium, Norway, Israel, Turkey, India, and Taiwan (allk = 1); two studies were conducted internationally; first,in Qatar, Hong Kong, and Japan [19], and the US andCanada [39]. Studies were published between 1994 and2018 (Mdn year of publication 2016, only n = 9 before2010 and n = 1 before 2000).
Study designEleven studies evaluated an intervention; of these, 10utilised pre- post AB designs and one adopted a rando-mised controlled trial design. Other studies used cross-sectional survey or qualitative designs. Interventionstudies sometimes incorporated additional qualitative ordescriptive elements.
Outcome measuresThe most commonly used measure employed was thePHASe or some adaptation of it [11] in seven studies re-ported across eight papers [11, 19, 20, 40–44]. The PHASecomprises four factors: 1. Nurses’ attitudes to physicalhealth care; 2. Nurses’ confidence to provide physicalhealth care; 3. Nurses’ perceived barriers in providing phys-ical health care; and 4. Nurses’ attitude towards smoking.Contact with study corresponding authors (Bressington,Chee, Haddad) resulted in acquisition of additional PHASetotal and subscale information that was not included in therespective published study papers. Two other outcomestools were used in two studies each, these being thepurpose-designed survey measure of Howard and Gamble[45] subsequently used by Terry and Cutter [46], andHappell’s [33] own questionnaire adapted for use by Clancyet al. [40]. Most studies used purpose-designed tools.Many reported sufficient information to allow confi-dence about their internal reliability and face/contentvalidity but there was little information about theirmeasurement reliability, criterion validity, or sensitiv-ity to change (see Additional file 5: Table S5). A smallnumber of papers used existing validated measures[47–52] and these were generally the most robusttools (see Additional file 6: Table S6).
Study qualityAll K = 7 qualitative studies were rated very highly interms of their quality on a 10-point assessment (Mdn = 9,range 9–10). Cross-sectional observational studies met amedian of four of seven quality criteria (range two to six;mean[SD] 4.43[1.33]). Four of these provided an a priorisample size calculation and there was a lack of valid out-come measures in nine of the 21 studies. Overall risk of
bias for cross-sectional studies was judged to be low fornine studies, unclear for six and high for six. The qual-ity of interventional studies was generally the poorest(Mdn = 5, range 2 to 7 of 10 indicators). Only twowere judged to be at low risk of bias (see Additionalfile 2: Tables S2, Additional file 3: Table S3, Additionalfile 4: Table S4, Additional file 5: Table S5 andAdditional file 6: Table S6 for further details). Com-mon omissions were, again, sample size justification,lack of repeat pre-baseline and follow up measures,and information about the representativeness of in-cluded samples.
Study synthesisNon-intervention studiesStudies examined physical healthcare in general (k = 24),sexual health (k = 4), smoking (k = 6), physical activityand healthy eating, nutrition - in particular the role ofOmega-3 in diet, mild brain injury, and breastfeeding(all k = 1; see Table 1).With regards to studies using the PHASe, of all pos-
sible comparisons across studies (see Tables 2 and 3),the mean score of the study sample differed significantlyfrom the reference sample [11] on 13 out of 21 (61.9%)subscale and three of four total score combinations(75.0%). Analysis revealed poorer attitudes compared tothe reference sample on all three of the significantlypoorer attitude scores on 10/17 (58.9%) subscale com-parisons, and better attitudes on three (14.3%). However,the reference group only outperformed the other studieson two of the eight possible comparisons on the sub-scales ‘Physical Healthcare’ and ‘Confidence in ProvidingPhysical Healthcare’ and was poorer for three compari-sons. The PHASe total score difference was greatest(large effect size) between the reference sample andChee et al’s [41] Australian sample (Cohens d = 1.13)followed by Bressington et al’s [19] Japanese mentalhealth nurse sub-sample (d = 0.72). For subscale scores,effect sizes for differences were also largest between thereference sample and that of Chee et al. [41]. Effect sizeswere in favour of the reference sample on the attitudesto smoking and barriers to physical healthcare subscales(d = 1.48 and 1.78 respectively). Next largest were differ-ences between Haddad et al’s [43] sample also on thebarriers to healthcare (d = 0.93) and attitudes to smokingsubscales (d = 1.01). On this occasion differences were infavour of Haddad et al’s [43] sample. Attitudes to smok-ing were more favourable than the reference sample intwo studies, comparable in one and poorer in two.Regarding the level of self-reported involvement in as-
pects of physical healthcare the proportion of respon-dents in PHASe-studies answering ‘strongly agree’ or‘agree’ to 14 items revealed considerable cross-sampledifferences. Of 95 possible comparisons between the
Dickens et al. BMC Nursing (2019) 18:16 Page 5 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
MHNsan
dph
ysicalhealthcare:C
ross-sectiona
land
qualitativestudies
Bressing
tonet
al.[19][2016–
17]
Qatar,H
ongKo
ng,
Japan
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire:PHASe
[11]
andJapane
setranslation
N=481MHNs(39%
respon
serate)57%
F;<5-yrsin
MH14%.
Routinepractice
National/Inter-
natio
nal
Nurses’attitud
esandconfiden
cepred
ictph
ysicalhe
alth
managem
ent
participation.Training
need
spe
rceivedacross
registratio
nand
natio
nality;espe
ciallycardio-
metaboliche
alth.
Brim
blecom
beet
al.[53]
[2005]
England
Mixed
.Cross-
sectional,qu
alitative.
Physicalhe
althcare.
Purpose-de
sign
edtool.C
ontent
analysis.
Researcher
catego
risationand
inferentialstatistics.
N=326subm
ission
sfro
mHighe
rEducation(HE)
and
care
organisatio
ns,
open
meetin
gs,
individu
alandMHN
grou
ps(n=119)
Con
sultatio
ndo
cumen
tNational
Prom
otinghe
althylifestylemost
common
lymen
tione
dby
HE
organisatio
ns.‘Ph
ysicalassessmen
tskills’wererequ
iredaccordingto
open
meetin
gsandNHS
organisatio
nrespon
dentsbu
tsign
ificantlyless
soby
individu
alor
grou
psof
MHNs.
ҪelikInce
etal.
[56]
[2017]
Turkey
Qualitative.Ph
ysical
healthcare.
Semi-structured
interviewson
physicalhe
alth
care
N=12
men
talh
ealth
nurses
Routinepractice
Twoho
spitals
Them
es:1.Barriersto
physical
healthcare;2.C
urrent
physical
healthcare
practices;3.M
otivatorsfor
providingph
ysicalhe
althcare;4.
Needs
ifph
ysicalhe
alth
care
isto
improve.
Che
eet
al.[41]
[2015]
Australia
Cross
sectional
survey.Physical
healthcare
inFirst
Episod
ePsycho
sis
care
Questionn
aire:
Amen
dedPH
ASe
[11]
N=207MHNsand
Gen
eralistnu
rses
working
inmen
tal
health
services
Routinepractice
National
Varyinglevelsof
physicalhe
alth
practice.SeeTable2
Clancyet
al.
[40]
[not
repo
rted
]
Australia
Cross
sectional
survey.Physical
healthcare.
Questionn
aire:
Adapted
PHASe
[11];
(Happe
llet
al.[30].
Add
ition
alitems.
N=385clinicians
andmanagers(n=
198nu
rses
51.4%
ona31%
respon
sediscipline-
rate)
Routinepractice
Service
MHNsratedas
having
strong
role
legitim
acy(m
onito
ring,
motivating,
supp
ortin
g)in
relatio
nto
physical
health
interven
tions,m
edication
effects,substanceuse,andsexual
health
both
inabsolute
term
sand
relativeto
mostothe
rdisciplines.
Delaney
etal.
[54]
[not
repo
rted
]
US
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire.
Researcher
catego
risationof
respon
sesand
descrip
tivestatistics.
N=1899
Advanced
PracticeMHNs
Routinepractice
National
Respon
dentsrarelyiden
tifyph
ysical
assessmen
t(<
4.0%
)or
pathop
hysiolog
y(0.5–5.0%)skills
asa
deficit.
Ganiahet
al.
[42]
[not
repo
rted
]
Jordan
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire:PHASe
[11].A
rabic
translation.
N=225MHNs;40.9%
F;M
expe
rience6.7-
yrs
Routinepractice
National
Sign
ificant
butsm
allcorrelatio
nsbe
tweenparticipants’attitu
desand:
repo
rted
physicalhe
althcare
practice
(r=0.39);yearsin
men
talh
ealth
care
(r=−0.207);M
nassign
edpatientspe
rnu
rse(r=−0.18)a
Dickens et al. BMC Nursing (2019) 18:16 Page 6 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies(Con
tinued)
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
Happe
llet
al.
[30]
[2012]
Australia
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire:
Mod
ified
PHASe
[11]
N=643see5.
Routinepractice
National
Varyinglevelsof
physicalhe
alth
practiceandattitud
es.See
Table3.
Happe
llet
al.
[31]
[2012]
Australia
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire:
Strategies
for
ImprovingPh
ysical
Health
ofCon
sumers
with
Serio
usMen
tal
Illne
ss.A
dapted
PHASe
[11]
N=643MHNs(22%
respon
se);72.7%
F;<
10-yrsin
MH15.7%
Routinepractice
National
Training
priorities:cardiovascular
health
(76.2%
);diabetes
(71.4%
);assessmen
tof
physicalillne
ss(69.2%
);weigh
tmanagem
ent
interven
tions
(68.6%
);exercise
(66.4%
);he
althyeatin
g(64.2%
);sm
okingcessation(63.0%
);reprod
uctivehe
alth
(62.4%
);sensitive
health
issues
(62.1%
).
Happe
llet
al.
[32]
[2012]
Australia
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire:Rate
strategies
for
improvingpatients’
physicalhe
alth
N=643see5.
Routinepractice
National
Highen
dorsem
entof
nurse-based
strategies
(lifestyleprog
rammes,
screen
ing),lessforredu
cing
antip
sy-
chotics.Mostvalueattached
tocolo-
catio
nof
men
taland
physicalhe
alth
services,trainingGPs.
Happe
llet
al.
[72]
[2012]
Australia
Qualitative.Ph
ysical
healthcare.
Focusgrou
ps:W
hat
training
need
edto
addressph
ysical
health
ofpatients?
N=38
MHNs;MH
expe
rience<1to
22-
yrs(M
dn=11-yrs)
Routinepractice
Region
Training
priorities:ph
ysicalhe
alth
care:p
hysicalassessm
ent,ph
ysical
observations,d
iabe
tes.Strong
beliefs
abou
tmod
esof
training
,accessto
training
,and
organizatio
nal
commitm
ent.
Happe
llet
al.
[73]
[2012]
Australia
Qualitative.Ph
ysical
healthcare.
Focusgrou
ps.Top
ics:
Physicalillne
ss:
physicalhe
alth
ofpatients;care
respon
sibility;patient
engage
men
t
N=38;M
Hexpe
rience<1to
22-
yrs(M
dn=11-yrs)
Routinepractice
Region
Com
mon
expe
rienceof
comorbid
physical/m
entalillnessin
clients.
Impo
rtantforhe
alth-careservices
totreatandpreven
tph
ysicalillne
ss.D
i-vergen
tview
son
nurses’capacity
tocontrib
uteto
better
outcom
es.
Stud
yanddata
collectionyear
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
esSample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
Happe
llet
al.
[33]
[2012]
Australia
Cross-sectio
nal
survey.Physical
healthcare.
Nurse
Collabo
ratio
nWith
Other
Staffon
thePh
ysicalHealth
ofCon
sumers
questio
nnaire
N=643see5.
Routinepractice
National
Physicalhe
alth
mostfre
quen
tlydiscussedwith
GPs,p
sychiatrists,
case
managers(M
dn=‘Often
’);least
with
OTs
andSW
s(M
dn=‘Never’).
Nurseswho
discussph
ysicalhe
alth
with
oneothe
rprofession
aremore
likelyto
discussitwith
asecond
type
(truefor52/56po
ssible(rang
er
=0.21
to0.59
a ).
Happe
llet
al.
[34]
[2012]
Australia
Cross-sectio
nal
survey.Physical
healthcare.
Adapted
PHASe
[11]
plus
new
items.
N=643see5.
Routinepractice
National
Physicalhe
alth
care
was
explaine
dby
self-repo
rted
nurseview
son
pa-
tient
health,rightsandnu
rserole
ideal(‘nursesshou
ldbe
involved
in
Dickens et al. BMC Nursing (2019) 18:16 Page 7 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies(Con
tinued)
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
physicalhe
alth
care’),andorganisa-
tionalfactors.The
latter
may
bemoreim
portantin
determ
ining
physicalhe
alth
care
Happe
llet
al.
[35]
[2012]
Australia
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire
domains:1.Perceived
RelativeHealth
;2.
Health
care
Arrange
-men
ts;3.Value
ofPh
ysicalHealth
care
Initiatives;4.C
ardio-
metabolicHealth
Nurse
(CHN)sup
port
N=643see5.
Routinepractice
National
Pred
ictorsof
CHNsupp
ort:be
liefin
GPph
ysicalhe
althcare
neglect,
interestin
training
;highe
rpe
rceived
valueof
improvingph
ysicalhe
alth
care
(stand
ardizedβcoefficients0.11.
0.14,and
0.27
respectively)b
How
ard&
Gam
ble[45]
[not
repo
rted
]
UK
Cross-sectio
nal
survey.Physical
healthcare.
Purpose-de
sign
edself-repo
rtqu
estio
nnaire
N=37
ward-based
MHNs(47%
re-
spon
se);Qualified<
5-yrs43%
Routinepractice.
Service
Gap
betw
eenpe
rceived
respon
sibilityandpractice
high
lightingne
edforrole
clarificatio
nandskillstraining
Mweb
e[55]
[not
repo
rted
]UK
Qualitative.Ph
ysical
healthcare.
Semi-structured
interviewson
physicalhe
alth
mon
itorin
g
N=11
MHNs;<10-
yrsleng
thof
service
72.7%
Routinepractice.
Service
Com
mitm
entto
physicalhe
alth
screen
ingandmon
itorin
grole.
Them
es:current
practice;pe
rceived
barriers;edu
catio
naln
eeds;strateg
ies
toim
prove
Nash[71]
[not
repo
rted
]UK
Cross
sectional
survey.Physical
healthcare.
Purposede
sign
edself-repo
rtqu
estio
nnaire
N=179MHNs(53%
respon
se);M-yrsqu
al-
ificatio
n3.5,<10-yrs
58%
Routinepractice
Service
58%
expe
rienced
inph
ysicalhe
alth
care
giving
;55%
received
training
;71%
curren
tlyprovidingph
ysical
care:d
iabe
tes(53%
),cardiac(23%
),chest(19%
),skin
(32%
),analge
sia
(32%
),de
tox(13%
).Training
need
s:96%
willingto
attend
skillstraining
.
Osborne
etal.
[47]
[not
repo
rted
]
Australia
Cross-sectio
nal
survey.Physical
assessmen
tskills
PhysicalAssessm
ent
SkillsInventory[74,
75]Barriersto
Registered
Nurses’
Use
ofPh
ysical
Assessm
entScale[76]
N=433registered
nurses
includ
ing34
(7.8%)men
talh
ealth
nurses;90.8%
F;<
3-yearsexpe
rienceas
RN10.8%.
Routinepractice
Hospital
Men
talh
ealth
nurses
usefewer
(7/
21)‘core’ph
ysicalassessmen
tskills
(tho
seused
onaverageeveryday)
than
nurses
inothe
rspecialties
(surgical;maternity;m
edical;
oncology;m
ean=10.2).Theskills
mostregu
larly
used
bymen
tal
health
nurses
(measurin
gtempe
rature
73.5%,m
easurin
gSpO2,76.4%,m
easurin
gbloo
dpressure
70.6%)areless
common
lyused
than
byallo
ther
nurses
((85.6,
85.4,and
75.4%
respectively).
Phelan
[77]
[not
repo
rted
]UK
Aud
it.Ph
ysical
healthcare.
Physicalhe
alth
care
(PHC)che
cktool
60commun
ity-based
clients.PH
Ccom-
pleted
byMHNs
Routinepractice
Team
Moreprob
lemsin
thisgrou
pof
patientsthan
inan
auditof
records
from
asimilarteam
notusingPH
C.
Dickens et al. BMC Nursing (2019) 18:16 Page 8 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies(Con
tinued)
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
(68.3%
)Tool
seem
sto
help
nurses
iden
tify
prob
lems.
Robson
&Haddad[11]
[2006–7]
UK
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire:PHASe
N=585MHNs;62.2%
FRo
utinepractice
Region
Varyinglevelsof
physicalhe
alth
practiceandattitud
es.See
Tables
2and3.
Robson
etal.
[20]
[2006–7]
UK
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire:PHASe
[11]
N=585MHNssee10
Routinepractice
Region
Varyinglevelsof
physicalhe
alth
practiceandattitud
esSeeTables
2and3
Shueletal.[78]
[2007–8]
UK
Aud
it/Survey
Physicalhe
althcare.
Serio
usMen
tal
Health
Improvem
ent
Profile
(HIP),short
semi-structured
interviews
N=31
patientsseen
bytw
oHIP-trained
MHNs
Use
ofHIP
inroutinepractice
Service
TheHIP
used
byMHNsiden
tifies
someph
ysicalissues.A
utho
rsrecommen
dthat
training
isrequ
ired
ifthey
areto
useiteffectively.
Wynaden
etal.
[44]
[2014]
Australia
Cross-sectio
nal
survey.Physical
healthcare.
Questionn
aire:PHASe
N=170nu
rses
inpu
blicmen
talh
ealth
services
Routinepractice
Threeservices
Workplace
cultu
reinfluen
cesthe
physicalhe
alth
care
provided
.Nurses
areun
certainabou
twhe
rethere
prioritieslie.
Stud
yanddata
collectionyear
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
esSample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
MHNsan
dph
ysicalhealthcare:Lon
gitudina
l/Interventionstudies
Fernando
etal.
[66]
[not
repo
rted
]
UK
Long
itudinalA
B.Ph
ysicalhe
althcare.
Purposede
sign
edqu
estio
nnaire
N=63
nurses
and
junior
doctors
(15[24%]MHNs)
Physical/men
tal
health
simulation
Region
Totalkno
wledg
e,attitud
es,and
confiden
cescores
improved
butno
data
specificto
delirium.
Haddadet
al.
[43]
[not
repo
rted
]
UK
Long
itudinalA
B.Ph
ysicalhe
althcare.
Questionn
aire:PHASe
[11]
N=49
(respon
se60%);<10
yearssince
qualificatio
n60%.
Low
secure
men
tal
health
unit.
Patient
person
alhe
alth
plan
Worksho
p.
Service
Mod
est(d=.09)
statistically-
sign
ificant
improvem
entin
staff
know
ledg
escores
andattitud
esto
involvem
entin
physicalhe
alth
care.
SeeTables
2and3
Hem
ingw
ayet
al.[68][not
repo
rted
]
UK
Long
itudinalA
B.Ph
ysicalhe
althcare.
Multip
lechoice
form
atknow
ledg
equ
estio
nnaire
N=204(n=89
registered
and115
stud
ents).Mdn
age
39-yrs
5×1-dph
ysical
healthcare
worksho
ps
Region
Allknow
ledg
eareassign
ificantly
improved
from
Ato
B.Effect
sizesd
=1.4wou
ndcare
to4.6diabetes
via
1.7Oralh
ealth
,2.79IM
injections
and2.74
HIP).Alm
ostallp
articipants
satisfiedor
very
satisfiedc
Terry&Cutter
[46]
[not
repo
rted
]
UK
Long
itudinalA
Bplus
qualitative.Ph
ysical
healthcare.
Purpose-de
sign
edself-repo
rtqu
estio
n-naire
[45]
15MHNsin
ABstud
y,5in
focusgrou
p;<3-
yrsin
post23.1%
Physicalcare
degree
mod
ule
Mod
ulecoho
rt.
Mconfiden
ce97.9T1
to121.1T2,p
<.001
r=0.98.Improvem
entson
25/
39qu
estio
nnaire
items.Focus
grou
ps:p
hysicalh
ealth
care
becomingmoreim
portantin
practice.Lack
info
andwantmore
know
ledg
e.a
White
etal.
UK
Long
itudinalA
B.Kn
owledg
eof/
N=38
matched
pairs
2.5hph
ysical
Region
Statisticallysign
ificant
know
ledg
e-
Dickens et al. BMC Nursing (2019) 18:16 Page 9 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies(Con
tinued)
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
[67]
[not
repo
rted
]Ph
ysicalhe
alth.
attitud
esto
(10
MCQs)ph
ysical
health
insevere
men
talillness
78.3%
F;<5-yrsin
health
care
47.9%
health
work-
shop
.HIP
gain
post-w
orksho
p(d=1.16).Partici-
pantssatisfiedwith
conten
tandwill-
ingto
applylearning
c
MHNsan
dcareforspecificph
ysicalhealth
issues:Cross-sectiona
land
qualitativestudies
Artzi-M
edvdik
etal.[48]
[2006]
Israel
Cross-sectio
nal
survey.Breastfe
eding
inwom
enwith
schizoph
renia
diagno
sis.
Know
ledg
eand
attitud
esto
breastfeed
ing[79].
Adapted
Attrib
ution
Questionn
aire-27[80]
N=110(re
spon
se57.9%)FRN
spracticingin
psychiatry/obstetrics
(MHNn=37;M
yrs.
registered
6.64];
Midwifery
n=40;
postpartum
care
n=33).
Routinepractice
MHNsvs.
Midwives
vs.
Post-partum
care
Positiveattitud
esto
breastfeed
ingin
mothe
rswith
schizoph
reniain
70%
ofrespon
dentsandto
wom
enwith
schizoph
renia.MHNssign
ificantly
less
know
ledg
ere:b
reastfeeding
,po
orer
attitud
esto
breastfeed
ing,
moreknow
ledg
eabou
tschizoph
renia.Pred
ictorsof
positive
attitud
etowards
breastfeed
ingin
wom
enwith
schizoph
renia:
academ
iced
ucation(OR=2.87),fear
ofschizoph
renicpatient
(OR0.27),
extend
edschizoph
renia-related
know
ledg
e(OR=0.35)d
Dorsay&
Forchu
k[59]
[not
repo
rted
]
Canada
Cross-sectio
nal
survey.Sexualh
ealth
Purpose-de
sign
edsurvey
questio
nnaire
N=66
MHNs
(respon
se20%)
Routinepractice.
Service
Participantsknow
ledg
eableand
compe
tent.M
ostcommon
sexual
issues
wereabuse,contraception,
STDs.Patient
interviewssugg
ested
mosthadno
tbe
enapprop
riately
engage
din
conversatio
n.
Happe
ll&
Platania-Phu
ng[35]
[2012]
Australia
Cross-sectio
nal
survey.C
ardio-
vascular
health
prom
otion
Adapted
PHASe
[11]
plus
new
items.
N=643see5.
Routinepractice
National
Perceivedpatient–n
urse
collabo
ratio
nas
adu
al-determinant
ofnu
rsepe
rceivedbarriersandself-
repo
rted
health
prom
otionto
pa-
tientswith
SMI.Perceivedbarriersto
consum
erlifestylechange
didno
tpred
icthe
alth
prom
otion.Theeffects
ofnu
rse–patient
collabo
ratio
nwere
sign
ificant,b
utsm
all.
Happe
llet
al.
[36]
[2012]
Australia
Cross-sectio
nal
survey.C
ardio-
metabolicHealth
Nurse
Role
133op
encommen
tsabou
ttheroleof
the
CHN
N=643see5.
Routinepractice
National
Nursesseethespecialistroleas
suitableandvaluableformen
tal
health
services.Som
econcerns
abou
trolefragm
entatio
nwith
increasing
specialty.
Happe
llet
al.
[38]
[2012]
Australia
Cross-sectio
nal
survey.D
entalh
ealth
.Adapted
PHASe
[11]
plus
new
items.
N=643see5.
Routinepractice
National
Themajority
ofnu
rses
considered
theoralandde
ntalcond
ition
sof
peop
lewith
serio
usmen
talillnessto
beworse
than
thewider
commun
ity.
Whe
ncomparedwith
arang
eof
sign
ificant
physicalhe
alth
issues
(e.g.
Dickens et al. BMC Nursing (2019) 18:16 Page 10 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies(Con
tinued)
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
cardiovascular
disease)
Hug
hes&Gray
[63]
[not
repo
rted
]
UK
Cross-sectio
nal
survey.H
IV/AIDS
Purpose-de
sign
edqu
estio
nnaire
283Men
talh
ealth
workers(44%
respon
se).51%
nurses
Routinepractice
Region
Sexualhe
alth
prom
otion:partof
role
(80.3%
);mandatory
training
requ
ired
(78.3%
);comfortablewith
LGBT
issues
(71.3%
).Peop
lewith
SMI
shou
ldbe
discou
rage
dfro
mhaving
sex(1.8%);Discussingsexualactivity
encourages
it(4.3%);ok
totestHIV
status
with
outpatient
consen
t(4.6%).
Johann
essenet
al.[62][not
repo
rted
]
Norway
Qualitative.Omeg
a-3/
Nutrition.
Questionn
aires
(stude
nts)and
interviews
n=50
stud
ent
nurses;n
=20
tutor
nurses;n
=5
psychiatrists.
Routinepractice
Region
Nutritionconsidered
impo
rtantbu
tfew
evaluatio
nsaremade.Lack
ofOmeg
a-3know
ledg
e.Unclear
divi-
sion
sof
respon
sibility.
Klein&Graves
[39]
[2014]
US/
Canada
Cross-sectio
nal
survey.M
ildbrain
injury
(MBI).
Onlinesurvey
questio
nnaire
N=1049
nurse
practitione
rs(23%
respon
se)inc.139
MHNPs
(84.3%
F;<5-
yras
NP25.4%)
Vide
oof
standardised
MBI
patient
National/cross-
border
MHNpractitione
rssign
ificantlyless
likelyto:havehadrelevant
training
,thinktheinjury
isaconcussion
,use
standardized
instrumen
ts.Rep
orted
discom
fortwith
thesurvey
asdu
eto
know
ledg
ede
ficit.Less
likelyto
have
hadrelevant
training
.
Stud
yanddata
collectionyear
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
esSample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
Magor-Blatch&
Ruge
ndyke[50]
[not
repo
rted
]
Australia
Cross-sectio
nal
survey.Smoking.
Attitu
destoward
SmokingScale[81]
Shoreet
al
N=98
Men
talH
ealth
Practitione
rs(n=9
nurses)allsettin
gs
Routinepractice.
Region
44.9%
approved
smoke-fre
epo
licy.
Attitu
desto
smokingrestrictio
ns(r=
0.35),concerns
re:secon
dhand
smoke(r=0.37),andto
relatio
nships
with
smokers(r=.39)
associated
with
smoke-fre
eagreem
ent.Onlyatti-
tude
spro-
(positive
relatio
nship),and
anti-
thesm
okingban(neg
ativerela-
tionship)
pred
ictedbansupp
orta
Nash[82]
[not
repo
rted
]UK
Cross-sectio
nal
surveyDiabe
tes
16-item
questio
nnaire
N=138MHNs
(respon
se63%);
qualified
<3-yrs26%;
Routinepractice
Service
69%
curren
tlyprovidingdiabetes
care
(mostdaily
orweeklyor
bi-
weekly65%)Needfortraining
inall
aspe
ctsof
diabetes
care.64%
had
notreceived
training
,86%
requ
ired
furthe
rtraining
.
Pareletal.[65]
[Not
stated
]India
Cross-sectio
nal
survey.Smoking.
Purpose-de
sign
edsurvey
questio
nnaire.
N=45
nurses
ina
psychiatric
departmen
t.
Routinepractice
Dep
artm
ent
Mod
erateor
greaterknow
ledg
eabou
ttobaccosm
okingand
smokingcessationam
ong
participants.C
essatio
n-training
and
attitud
esto
cessationne
gatively
associated
.
Dickens et al. BMC Nursing (2019) 18:16 Page 11 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies(Con
tinued)
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
Quinn
etal.
[83]
[not
repo
rted
]
Australia
Qualitative.Sexual
health
In-dep
th1:1
interviewsabou
texpe
rienceof
discussing
sexuality
with
patients.
14MHNs;57%
F;MHNexpe
rience2–
39yrs.(M
=14.9)
Routinepractice.
Service
Com
mon
referenceto:sexual
functio
nassessmen
t,psycho
trop
icside
-effects,patient
embarrassm
ent,
andpros
andcons
ofinform
ation.
Sexualside
effectsrecogn
ised
asim
pactingon
med
icationadhe
rence
butmostdidno
tdiscussitwith
patients.
Quinn
etal.
[60]
[Not
stated
]
Uk&Australia
Cross-sectio
nal
survey.Sexualh
ealth
care/
Purpose-de
sign
edsurvey
questio
nnaire.
Amen
dedfro
mHug
hesandGray[63]
N=303(n=219and
84fro
mAustraliaand
UKrespectively)
Routinepractice
International
Theresults
demon
stratedthat
men
talh
ealth
nurses
dono
troutinelyinclud
esexualhe
alth
intheirpracticeandarepo
orly
prep
ared
inknow
ingwhatto
dowith
asexualhe
alth
issue,andwhat
services
toassistpatientsto
use.
Sharmaet
al.
[64]
[not
repo
rted
]
Australia
Cross-sectio
nal
survey.Smoking.
Onlinenatio
nal
survey
questio
nnaire
basedon
Ford
etal.
[84]
N=267men
tal
health
clinicians
(22.8%
nurses)
Routinepractice
National
Com
paredwith
areferencecatego
ryof
med
icalpractitione
rs,nurseswere
onlysign
ificantlyless
likelyto
arrang
efollow
upof
smoking
cessationinterven
tions
butno
tto
ask,assess,advise,or
assist.Training
insm
okingcessationassociated
with
morecessation-relatedhe
lpingbe
-haviou
r.Mostbe
lieve
harm
redu
c-tio
napproaches
tosm
oking
cessationareeffective.
Sharpet
al.[58]
[not
repo
rted
]US
Cross-sectio
nal
survey.Smoking.
Questions
assessing
interven
tionskills
followed
Ask–A
dvise–
Assess–Assist–
Arrange
recommen
datio
ns[85]
N=1381
MHNs
(app
rox.33%
respon
se);<5-yrs
expe
riencein
MHN
17.2%
Routinepractice
National
Mostnu
rses
assessed
patientsfor
smoking;
fewer
advisedagainst
smoking,
referred
forcessation,or
delivered
cessationinterven
tions.
Moreknow
ledg
eable/self-efficacious
nurses
referred
patientsto
smoking
cessationresources(d=0.41
to0.8)
orprovided
intensiveinterven
tions
(d=0.45
to0.73);thosewith
cessation-
consistent
beliefsmore
likelyto
refer(d=0.48
to0.49)or
provideinterven
tion(d=0.49–0.90)c
Verhaege
etal.
[61]
[not
repo
rted
]
Belgium
Qualitative.Health
prom
otion.
Focusgrou
ps(staff)
interviews(patients)
N=17
MHNs;N=15
patientsho
meless
service
Routinepractice
Service
Bene
fitsof
physicalandmen
tal
health
iden
tified,
butbarriersto
integratinghe
althylifestylesinto
patients’lives:lackof
timeand
person
alview
sandattitud
estowards
health
prom
otionwereim
portant.
Dickens et al. BMC Nursing (2019) 18:16 Page 12 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies(Con
tinued)
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
MHNsan
dcareforspecificph
ysicalhealth
issues:Longitudina
l/interventionstudies
Happe
llet
al.
[36]
[not
repo
rted
]
Australia
Long
itudinalA
Bsurvey.C
ardio-
metaboliche
alth.
14-item
questio
nnaire
N=42
nurses
initially
andN=21
atfollow-
up.
Introd
uctio
nof
aCHN
Service
Nursesinitiallysupp
ortiveof
therole.
6-mon
thtrialo
faCHNredu
cedam
-bivalence.Onlyon
eof
14itemssta-
tisticallysign
ificant
ACHNwou
ldhe
lppreven
ton
setof
cardio-
metabolicdisordersin
patientss;
greaterprop
ortio
ngave
anegative
respon
seat
post-in
terven
tion(d=
0.59)c
Hem
ingw
ayet
al.[70]
UK
Long
itudinalA
B.Diabe
tes
MCQ
12items.
Cou
rseevaluatio
nqu
estio
nnaire.
26stud
entnu
rses
and9qu
alified
staff.
See36
Mim
provem
entd=1.37.Both
stud
entsandqu
alified
improved
equally.C
ourseevaluatedwell.c
Hem
ingw
ayet
al.[69][not
repo
rted
]
UK
Long
itudinalA
Bplus
qualitativeelem
ent.
Diabe
tes
Custom
MCQ13
items;10-item
evalu-
ationqu
estio
nnaire.
Con
tent
analysisof
open
ende
dqu
estio
ns.
N=48
(22stud
ents,
26qu
alified
)DVD
,present-
ations,skills
sessions.
Region
M(SD)P
re-5.9(2.17)Po
st7.04(1.85),
p<0.01
(d=0.56)Cou
rseevaluated
high
ly.The
mes:Satisfaction;
Sugg
estio
nsto
improve;Use
ofalife
story;Clinicalpe
rspe
ctive.
Stud
yanddata
collectionyear
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
esSample
Interven
tion
Levelo
fanalysis
Mainfinding
s
Hun
teret
al.
[49]
UK
Mixed
.Lon
gitudinal
AB.Qualitative.
Obe
sity.
NursesAttitu
des
towards
Obe
sity
and
Obe
sePatientsScale
[86].Focus
grou
ps.
39/205
eligible
participated
pre-test
and29/39completed
both
Pre-
andpo
st-)
Simulation
‘bariatric
empathysuits’.
Stud
entcoho
rtNATO
OPS
αacceptableoverall.
Factor
50.541/0.414at
pre−
/post.
Pre-
postdifferences
onF1
F2and
F5.N
odifferences
onbe
tween
grou
pattitud
es.Q
ualitativethem
es:
Physicalim
pact
ofthesuit;
psycho
socialim
pact
ofthesuit;
thinking
differently;sim
ulationas
learning
expe
rience;challeng
esand
recommen
datio
ns.
Sung
etal.[51]
[not
repo
rted
]Taiwan
Stage1:Qualitative.
Stage2:RC
T.Sexual
health.
1.FocusGroup
;2.
Know
ledgeof
sexual
healthcarescale;
Attitudetowardsexual
healthcarescale.Self-
efficacyforsexual
healthcarescale:
Stage1:16
nurses,M
clinicalexpe
rience
15.9-yrs,100%
F.Stage2:N=11759
Expe
rimen
tal58
Con
trol.n
MHNs
unclear:allocatio
nstratifiedto
ensure
represen
tatio
n.
Stage1:Non
e.Stage2:Sexual
healthcare
training
16-h
over
4-weeks.
Service
Stage1:them
es:a)View
sand
expe
riencein
dealingwith
sexual
healthcare
b)Expe
ctations
re:
training
.Stage
2:Expe
rimen
talg
roup
sign
ificant
improvem
entsin
know
ledg
e(d=1.02),attitud
e(d=
0.67),andself-efficacy(d=1.02).
Relativeto
controls,the
ymadesig-
nificantly
greaterknow
ledg
eim
-provem
ents(β=−0.12,p
<0.01)and
attitud
es(β=−0.25,p
<0.05),bu
tno
tself-efficacy(β=−0.33,p
=0.18).
Nopsychiatric
versus
othe
rward-
type
effectb,c
Dickens et al. BMC Nursing (2019) 18:16 Page 13 of 21
Table
1Men
talh
ealth
nurses
andph
ysicalhe
althcare
(kno
wledg
e,expe
rience,attitud
es,edu
catio
n)Includ
edstud
ies(Con
tinued)
Stud
yand
[datacollection
year]
Locatio
nStud
yde
sign
and
focus
Datasources/
outcom
es/analysis
Sample
Interven
tion/
Expo
sure
Levelo
fanalysis
Mainfinding
s
Wynn[52]
[not
repo
rted
]US
Long
itudinal
ABD
iabe
tes.
Clinicaljudg
men
trubric[87].D
iabe
tes-
relatedmed
ical
transfer.
N=20
MHNsin
veterans
men
tal
health
hospital
Simulations
rediabetes
care.
Service
Statisticallysign
ificant
prepo
stim
provem
entscores
onclinical
judg
men
t(d=4.8).Propo
rtionof
med
icalem
erge
ncyrepo
rtsinvolving
diabetes
fellfro
m55
to20%
inpo
st-
interven
tionmon
th.
a Pearson
’srSm
all=
0.3,
Mod
erate=0.5,
Large=0.7;
bStan
dardised
βcoefficient
outcom
evaria
blerises
bystated
amou
ntforeach
1SD
unitchan
gein
thepred
ictorvaria
ble;
c d=Coh
en’sd0.2Sm
all0
.5Med
ium
0.8
Largeeffect
size
dOROdd
sRa
tiorelativ
eriskof
thepred
ictorvaria
blewith
thereferencevaria
blee.g.
extend
edkn
owledg
eassociated
with
positiv
eattitud
esOR0.35
means
ape
rson
with
extend
edkn
owledg
eison
ly35
%as
likelyto
have
positiv
eattitud
esthan
someo
newith
outextend
edkn
owledg
e
Dickens et al. BMC Nursing (2019) 18:16 Page 14 of 21
reference study and others, 70 (73.7%) differed signifi-cantly. Of these, 86.7% compared unfavourably with theUK reference study, 13.3% favourably). The number ofitems per sample differing from the reference sampleranged from 7 to 13 (Mdn = 10). Japan [19] provided theonly sample of mental health nurses whose responsescompared favourably with the reference sample (7/10significantly differing responses being more favourablein the Japanese sub-sample), while Ganiah et al’s [42]sample (0/11 favourable comparisons among signifi-cantly differing responses), Happell et al’s [30] (0/14favourable comparisons), Chee et al’s [41] Australian
sample (1/11 favourable comparisons), Haddad et al’s[43] UK sample (1/10 favourable comparisons) and Bres-sington et al’s [19] Hong Kong sample (2/12 favourablecomparisons) all fared poorly. Items relating to checkingGP-status, advising on exercise, weight management,healthy eating, contraception, and eyesight checks wereall rated less favourably by at least two other samples(range 2 to 6, Mdn = 4) and more favourably by nonecompared with the reference sample. Only the itemabout ensuring patients have had their general physicalhealth assessed on first contact with mental health ser-vices was rated more favourably by two samples and less
Table 3 PHASe n and proportion who respond ‘Always’ or ‘Very often’ when asked with what frequency they conduct 14 physicalhealthcare-related items when working with mental health clients
*p < .05 **p < .01 ***p < .001 ˅ Compares unfavourably with reference sample; ˄ Compares favourably with reference sample; NS Not significant; FEP First EpisodePsychosis. a “How often do you undertake each of the following practices with consumers?” (response options: never, rarely, often, very often, always) vs. ‘Mycurrent practice involves… (response options: never, rarely, often, very often, always) bNo data presented for three items. Bold indicates the sample with the mostfavourable response by statement.
Table 2 PHASe M (SD) across subscales and totals by study and comparisons with reference study [11]
Physical health careM SD
Confidence toprovide physicalhealth careM SD
Nurses’ perceivedbarriers to deliveringphysical healthcareM SD
Nurses’ attitudesto smokingM SD
PHASeTotalM SD
Bressington et al. [19] All 34.39****˅ 5.20 21.79* ˅ 4.07 20.43**** ˅ 4.06 19.07****˄ 3.20 95.68****˅ 11.81
Qatar 35.5NS 5.45 24.69**** ˄ 2.71 19.71**** ˅ 4.32 18.00** ˄ 3.07 97.89 *˅ 8.93
Hong Kong 34.03**** ˅ 5.83 23.29** ˄ 2.89 20.31**** ˅ 4.37 19.38**** ˄ 3.23 97.01 **˅ 11.60
Japan 33.89**** ˅ 4.37 18.71**** ˅ 3.46 21.02**** ˅ 3.54 19.58**** ˅ 3.11 93.2****˅ 8.29
Chee et al. [41] a 36.87NS 6.00 23.73**** ˄ 2.50 17.24 **** ˅ 3.00 12.29**** ˅ 3.50 90.13**** ˅ 6.44
Ganiah et al. [42] 26.19 b 3.34 23.46**** ˄ 2.89 24.66*^ 3.08 15.02**** ˅ 2.7 89.33**** ˅ 5.55
Haddad et al. [43] 39.86*** ˄ 5.71 21.77NS 4.26 20.14**** ˅ 3.73 20.88**** ˄ 2.69 102.61 NS 10.75
Wynaden et al. [44] – – – – – – 17.82NS 2.71 – –
Robson et al. [11] (Reference sample) 36.62 6.43 22.31 3.63 23.92 4.34 17.62 3.71 100 10.53aData from personal correspondence. bScale 1 Based on 8/10 items (not breast examination or contraceptive advice) and therefore cannot calculate differencefrom reference M for this scale or PHASe total. **** p < .0001 *** p < .001 **p < .01 * p < .05 (Differs from reference group M ˄ favourably ˅ unfavourably)
Dickens et al. BMC Nursing (2019) 18:16 Page 15 of 21
favourably by none compared with the reference sample.For all other items there were item-level variations withno clear pattern.The remaining non-intervention studies provide a
mixed and sometimes contradictory picture. First, interms of reported use of physical health care skills,Osborn et al’s [47] study revealed that nurses working inmental health settings in one large hospital were lesslikely to use physical healthcare skills than colleagues inmedical, oncology, maternity and surgical settings.Further, they reported using a smaller range of relevantskills. In Howard and Gamble’s [45] survey, nurses’ re-sponses indicated a gap between their perceived respon-sibilities for physical healthcare and their practice.Elsewhere, compared with those responding on behalf ofhealthcare and educational organisations, nurses wereless likely to endorse their role in physical healthcareprovision [53] and they reported very low levels of en-dorsement of related skills training need [54]. However,for others in more recent studies, they displayed a clearcommitment to the physical healthcare role [55], andsaid they want more training [31, 56]. Further, nursesstrongly endorsed their own role in physical health, sex-ual health, and substance abuse related care and weresupported strongly by other healthcare professionals[40]. Across a series of linked surveys and qualitativestudies, Happell et al. [30–37, 57] reported associationsbetween nurses’ positive evaluation of the physicalhealthcare role and practicing aspects of it more com-monly. In studies of nurses and specific physicalhealthcare-related activities there was a suggestion thatrespondents’ own values or beliefs might be more influ-ential in determining their health-giving or advising be-haviour in relation to smoking cessation [50, 58]. Inrelation to sexual health, both Dorsay and Forchuk [59]and Quinn et al. [60] have reported that nurses cite pa-tient embarrassment as a reason for not asking patientsabout sexual side effects of antipsychotic medications.Lack of time, resources and knowledge were reported asbarriers to providing advice and interventions regardingexercise and physical activity [61], Omega-3 [62]. Know-ledge and attitudes to HIV/AIDS were generally good[63]. Finally, smoking-cessation training was associatedwith more smoking-cessation helping behaviour [64]though, counter-inuitively, training was negatively asso-ciated with attitudes to smoking cessation in a singlestudy [65]. Further, Sharma et al’s [64] study comparedthe attitudes of mental health trained nurses and com-prehensive/ generalist trained nurses working in mentalhealth services: the most marked differences betweenthe groups were on the smoking-related items with theformer group expressing significantly more liberal viewsabout smoking restrictions, more worrying attitudesabout the benefits and utility of cigarette use as a
therapeutic tool, and less confidence in the ability ofmental health patients to quit smoking. This was par-ticularly concerning in the study context which wasabout attitudes to physical healthcare with younger, firstepisode psychosis patients.
Intervention studiesFive studies focused on physical healthcare in generaland six on specific issues (diabetes n = 3; sexual health,cardiometabolic health, obesity all n = 1). Ten evaluatedan educational innovation, the exception being Happellet al. [35], who examined attitudes among nurses to theintroduction of a specialist cardiometabolic health nurserole. Haddad et al. [43] examined the impact of theintroduction of personal physical health care plans forpatients on nurses’ physical healthcare attitudes along-side the delivery of a single educational session on phys-ical healthcare assessment. The remaining nine studiesevaluated educational interventions including three in-volving simulation and six involving didactic teaching,workshop-format or blended-learning approaches.
Simulation studiesDuration of interventions was 30 min [49] and1-day[66], while information was not provided by Wynn [52].The mode of simulation delivery involved manikins [66],human actor as patient [66], software-based Human Per-son Simulator [52], and participant as ‘patient’ in whichstudent participants wore a 15 kg bariatric empathy suitwhile undertaking everyday tasks in order to help themappreciate the experience of obesity [49]. Other simula-tions involved diabetes care [52], fractured leg in thecontext of a jump or fall in a patient with first episodepsychosis, medical deterioration in the same patient fol-lowing transfer to a psychiatric ward, and delirium [66].Results indicated improved clinical judgement and re-duced diabetes-related medical emergency reports [52],improved knowledge, attitudes, and confidence aboutphysical healthcare [66], improved response to obese pa-tients, characteristics of obese patients and supportiveroles in caring for obese patients [49].
Non-simulation studieStudy duration ranged from a 2.5-h workshop on phys-ical health [67] to a 20-credit bachelor’s degree level(equivalent to 200-h of taught and self-directed studyand assessment completion) module on physical health-care in mental health [46]. Non-simulation studies eval-uated the introduction of personal health plans forpatients in a low secure forensic unit together with asingle educational session on physical health care fornursing staff [43]. Specific topics addressed included dia-betes [68, 69], health assessment [46, 67], oral health, IM
Dickens et al. BMC Nursing (2019) 18:16 Page 16 of 21
injectables [68], vital signs, blood readings, BMI meas-urement [46], and cardio-metabolic health [35, 57].In Sung et al’s [51] RCT, nurses were allocated in a
random stratified design to attend 8 × 2-h session aboutsexual healthcare over a period of 4-w or no interven-tion. Significant effects were detected in the experimen-tal group relative to the control group for improvementsin related knowledge and in attitudes, but not inself-efficacy. The study involved nurses employed bothin medical and psychiatric wards (stratified allocationfrom both) and there was no reported effect of ward-type on outcomes. Pretest- posttest design interventionstudies targeted at diabetes found greatly improvedclinical judgment in relation to diabetes care and re-duced diabetes-related emergency referrals [52] andsimilarly impressive improved diabetes-related know-ledge [69, 70]. Improved attitudes to obesity, obesepatients, and supportive roles in caring for obese individ-uals have been reported across a mixed group of partici-pants and did not differ between mental health and othernurses [49]. and physical healthcare in general. Happell etal. [57] reported improved support for a specialistcardiometabolic nurse role following its introduction,however we find this conclusion is unwarranted since it isderived from statistical testing of 14-questionnaire itemsonly one of which was found significant. Interventionsaimed at physical healthcare in general found some im-pressive post- group improvements in knowledge [66–68],attitudes [66], and confidence [46, 66].
DiscussionWe have conducted a systematic review of the empiricalliterature about mental health nurses and their attitudestowards, knowledge about, and experiences of physicalhealth care for patients. We took a broad approach tosearching the literature and included interventional andobservational studies involving real or simulated situa-tions. We included studies involving mental health nurs-ing students and multidisciplinary professional groups inaddition to those including only mental health nurses.We contacted study authors to gain additional informa-tion and, for the studies using the PHASe [11] and thiselicited significant, previously unpublished information.While we applied no time limits to our comprehensivesearch we found studies only from as early as 1994, onlynine from before 2000, and the median year of publica-tion was 2016. This means that there has been a wel-come increase, which we described as a ‘mini-explosion’in the Introduction, in related empirical work in recentyears. The total number of nurses involved in studies,7549, makes this to our knowledge one of the largestamalgamations of evidence gathered directly from men-tal health nurses.
However, the overall methodological quality of studieswas somewhat limited, particularly interventional studiesto improve mental health nurses’ physical healthcare as-sessment practices and skills. Nevertheless, while manyof the included studies examine mental health nurses,and nurses working in mental health settings, this groupcomprises a heterogeneous collection of individuals ofvastly differing experience, preparation, knowledge, androles. As a result, it is not too surprising that some lesswell-researched areas have thrown up starkly differentresults. However, there is consistent evidence that thereis a strong association between mental health nurses’ re-ported attitudes and their reported involvement in phys-ical health care [19, 20, 42]. Similarly, that the nurseswho value physical health care also report that they de-liver more of it [30] and those who talk to at least oneother discipline about their patients’ physical health doso with multiple professional groups [33]. Accordingly,fewer resources could be expended on answering thesesorts of associational questions in the future.Our conclusion is that it is now time for a new phase
for mental health nursing research related to physicalhealthcare: efforts must be redoubled to focus on devel-oping and testing interventions to improve nurses’ atti-tudes, knowledge, and skills. We must ensure that newstudies are well-designed and rigorously conducted.More specifically, further research is required to buildknowledge about whether the supposed benefits arisingfrom this relationship translate into objectively betterpractice and indeed better patient outcomes. This wouldstrengthen the case for training to improve attitudes andprovide some urgency to better understand what inter-ventions might deliver that outcome. Further, it appearsthat mental health nurses well-recognise that they re-quire further skills and knowledge related to physicalhealth care across a wide range of areas [19, 30, 31, 57,71]. However, ambivalence and reluctance remains aboutembracing the change needed to achieve this [61].The PHASe was used across multiple studies which
allowed for some international and setting-specific com-parison of nurses’ attitudes. We found that nurses’self-perceived practices and attitudes differed signifi-cantly between samples from across the world. This, ofcourse, may well reflect different approaches to mentalhealth nurse preparation; for example, in Australia, allpre-registration nurses undergo the same coreprogramme whereas in the UK mental health nursing isa specialist branch of pre-registration training. There-fore, results from Chee et al’s [41] recent study are en-lightening since they reveal equivalent attitudes tophysical healthcare specifically, more confidence in de-livering physical healthcare but poorer scores in relationto barriers to physical healthcare delivery and smokingcessation. Given the non-equivalence of results on the
Dickens et al. BMC Nursing (2019) 18:16 Page 17 of 21
attitudes to smoking subscale between Chee et al. [41]and Wynaden et al. [44], both conducted in WesternAustralia by related research teams, there are questionsabout the extent to which results are sample specific.Larger scale, representative data collection in Australiaand New Zealand could therefore add significantly tothe debate about nurses’ preparation for physical health-care skills under different preparation regimes. As thePHASe authors’ note, the tool has not been subjected totests of its stability or criterion validity and improve-ments in evidence for this would add significantly to theability to draw sound conclusions from research usingthe tool. Findings from Osborne et al’s [47] largehospital-wide survey indicate that the gap in the physicalhealth-related skills addressed by the PHASe is real andof concern.Apart from the PHASe the literature is peppered with
outcomes tools designed for single studies and with littleevidence of anything other than face validity and internalconsistency. Is it possible, we must ask, that this reflectsthat researchers are asking the wrong questions i.e.,focusing overly on mental health nurses’ attitudes andself-proclaimed knowledge and efficacy when what isnow required is a more robust approach to examiningtheir actual knowledge and performance and, crucially,their impact on patient outcomes. Little seems to havebeen added to the literature on this since Hardy et al.[23] found no studies to include in their systematic re-view. Further, Haddad et al’s [43] study in a low secureforensic setting found nurses scoring favourably onPHASe subscales about attitudes to physical healthcareand to smoking compared with non-forensic nurses inthe reference sample, suggesting perhaps that in a set-ting where length of stay is considerably longer thennurses have more opportunity to engage with patients inthis aspect of care. Notably, however, nurses in the samesample compared unfavourably with the reference sam-ple in terms of perceived involvement in actual physicalhealthcare, a somewhat contradictory finding.For intervention studies, effect sizes were generally lar-
gest, and were in fact sometimes startlingly large, whereinterventions were targeted and outcomes were know-ledge based (e.g., educational studies). This is unsurprisingsince educational interventions are generally evaluatedagainst criteria that are specifically and directly addressedin the intervention. Outcomes tended to be measured im-mediately following the training [46, 52], but their longterm retention is generally not known and neither is anypractical beneficial change to practice. The apparentpotency of these interventions requires further testing inrandomized designs with appropriate follow-up periods.Some study samples in the current review included
non-nursing staff; though their occurrence and representa-tiveness was too limited to allow robust conclusions to be
drawn about the relative state of nurses’ knowledge and at-titudes within the multidisciplinary team context. Given thecurrent review explicitly focused on mental health nursesthen further research exploring the multidisciplinary as-pects of physical health care provision is warranted.
ConclusionMental health nurses’ ability to provide routine physicalhealthcare has been highlighted in recent years. Recentliterature provides a starting point for future researchwhich must now concentrate on determining the effect-iveness of nurse preparation for providing physicalhealth care for people with mental disorder, determiningthe appropriate content for such preparation, and evalu-ating the effectiveness both in terms of nurse andpatient- related outcomes. At the same time, develop-ments are needed which are congruent with the needsand wants of patients. Perhaps what the included studiesbest demonstrate is that mental health nurses seem torealise that physical health care is part of their role.
Additional files
Additional file 1: Table S1. Example PICO-style electronic literaturesearch. Example literature search (DOCX 13 kb)
Additional file 2: Table S2. Controlled intervention evaluation studyquality assessment. Study Quality Assessment (controlled interventionstudy) (DOCX 13 kb)
Additional file 3: Table S3. Cross-sectional, observational studies qualityassessment (adapted from National Heart, Lung, and Blood Institute [26].Study Quality Assessment (Cross-sectional and observational studies)(DOCX 16 kb)
Additional file 4: Table S4. Longitudinal uncontrolled interventionstudy quality assessment. Study Quality Assessment (uncontrolledintervention studies) (DOCX 14 kb)
Additional file 5: Table S5. Qualitative study quality assessment. StudyQuality Assessment. (Qualitative studies) (DOCX 14 kb)
Additional file 6: Table S6. Outcome measure content and qualityassessment. Quality assessment of outcomes measures used in studies.(DOCX 25 kb)
AbbreviationsMeSH: Medical Subject Headings; PHASe: Physical Health Attitudes Scale formental health nurses; PICO: Population Intervention Comparator Outcome;PRISMA: Preferred Reporting Items for Systematic Reviews and Meta Analyses
AcknowledgementsNone.
FundingThe study was partly funded as part of the CUBIC Capability, Capacity andCultural Change project funded by Nursing and Midwifery Office (NaMO)New South Wales‘The funding body played no part in the in the design of the study,collection, analysis, interpretation of data, and in writing the manuscript.’
Availability of data and materialsAll data generated or analysed during this study are included in thispublished article [and its supplementary information files] and, whereapplicable data sharing is not applicable to this article as no datasets weregenerated or analysed during the current study.
Dickens et al. BMC Nursing (2019) 18:16 Page 18 of 21
Authors’ contributionsGLD conceived of and designed the study. GLD, RI, CW, EA, BE contributedto acquisition of data, analysis and interpretation of data. GLD, RI, CW, EA, BEcontributed to drafting the manuscript or revising it critically for importantintellectual content. GLD, RI, CW, EA, BE gave final approval of the version tobe published. GLD, RI, CW, EA, BE agreed to be accountable for all aspects ofthe work in ensuring that questions related to the accuracy or integrity ofany part of the work are appropriately investigated and resolved.
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Competing interestsThe authors declare they have no competing interests.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Author details1Professor Mental Health Nursing, Centre for Applied Nursing Research(CANR), Western Sydney University, Sydney, Australia. 2South West SydneyLocal Health District, Sydney, Australia. 3Division of Mental Health Nursingand Counselling, Abertay University, Dundee, Scotland.
Received: 30 October 2018 Accepted: 1 April 2019
References1. Walker ER, McGee E, Druss BG. Mortality in mental disorders and global disease
burden implications: a systematic review and meta-analysis. JAMA Psychiat.2015;72(4):334–41. https://doi.org/10.1001/jamapsychiatry.2014.2502.
2. Olfson M, Gerhard T, Huang C. Premature mortality among adults withschizophrenia in the United States. JAMA Psychiat. 2015;72(12):1172–81.https://doi.org/10.1001/jamapsychiatry.2015.1737.
3. Drope J, Liber AC, Cahn Z, Stoklosa M, Kennedy R, Douglas CE, Henson R,Drope J. Who's still smoking? Disparities in adult cigarette smokingprevalence in the United States. CA Cancer J Clin. 2018;68(2):106–15. https://doi.org/10.3322/caac.21444.
4. Annamalai A, Kosir U, Tek C. Prevalence of obesity and diabetes in patientswith schizophrenia. World J Diabetes. 2017;8(8):390–6. https://doi.org/10.4239/wjd.v8.i8.390.
5. Tomiainen M, Mittendorfer-Rutz E, Bjӧrkenstam C, Suvisaari J, AlexandersonK, Tiihonen J. Antipsychotic treatment and mortality in schizophrenia.Schizophr Bull. 2016;41(3):656–63. https://doi.org/10.1093/schbul/sbu164.
6. World Health Organisation. Guidelines for the management of physicalhealth conditions in adults with severe mental disorders. Geneva: WorldHealth Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO
7. New South Wales Government. Physical Health Care of Mental HealthConsumers. North Sydney: NSW Ministry of Health; 2017. Accessed 29Jan 2019: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2017_019.pdf
8. Nursing, Midwifery and Allied Health Professions Policy Unit. Improving thephysical health of people with mental health problems: Actions for mentalhealth nurses. London: Department of Health; 2016. Accessed 4 Jan 2019 at:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/532253/JRA_Physical_Health_revised.pdf
9. Royal Australian and New Zealand College of Psychiatrists. Keeping Bodyand Mind Together: Improving the physical health and life expectancy ofpeople with serious mental illness. Melbourne: Victoria; 2015. Accessed 29Jan 2019 at: https://www.ranzcp.org/files/resources/reports/ranzcp-keeping-body-and-mind-together.aspx
10. Department of Health. From values to action: the chief nursing Officer’sreview of mental health nursing. London: DOH; 2006.
11. Robson D, Haddad M. Mental health nurses' attitudes towards the physicalhealth care of people with severe and enduring mental illness: thedevelopment of a measurement tool. Int J Nurs Stud. 2012;49(1):72–83.https://doi.org/10.1016/j.ijnurstu.2011.07.011.
12. Blythe J, White J. Role of the mental health nurse towards physical healthcare in serious mental illness: an integrative review of 10 years of UKliterature. Int J Ment Health Nurs. 2012;21(3):193–201. https://doi.org/10.1111/j.1447-0349.2011.00792.x.
13. Happell B, Scott D, Platania-Phung C. Perceptions of barriers to physicalhealth care for people with serious mental illness: a review of theinternational literature. Issues Ment Health Nurs. 2012;33(11):752–61. https://doi.org/10.3109/01612840.2012.708099.
14. Happell B, Platania-Phung C, Scott D. A systematic review of nurse physicalhealthcare for consumers utilizing mental health services. J Psychiatr MentHealth Nurs. 2014;21(1):11–22. https://doi.org/10.1111/jpm.12041.
15. Collins E, Tranter S, Irvine F. The physical health of the seriously mentally ill:an overview of the literature. J Psychiatr Ment Health Nurs. 2012;19(7):638–46. https://doi.org/10.1111/j.1365-2850.2011.01831.x.
16. Estabrooks CA, Floyd JA, Scott-Findlay S, O’Leary KA, Gushta M. Individualdeterminants of research utilization: a systematic review. J Adv Nurs. 2003;43(5):506–20. https://doi.org/10.1046/j.1365-2648.2003.02748.x.
17. Melnyk BM, Fineout-Overholt E, Feinstein NF, Li H, Wilcox L, Kraus R.Nurses’ perceived knowledge, beliefs, skills and needs regardingevidence-based practice: implications for accelerating the paradigmshift. Worldviews Evid-Based Nurs. 2004;1(4):185193. https://doi.org/10.1111/j.1524-475X.2004.04024.x.
18. Varnell G, Haas B, Duke G, Hudson K. Effect of an educational interventionon attitudes toward and implementation of evidence-based practice.Worldviews Evid-Based Nurs. 2008;5(4):172–81. https://doi.org/10.1111/j.1741-6787.2008.00124.x.
19. Bressington D, Badnapurkar A, Inoue S, Ma HY, Chien WT, Nelson D, Gray R.Physical health care for people with severe mental illness. Int J Environ ResPublic Health. 2018;15(343). https://doi.org/10.3390/ijerph15020343.
20. Robson D, Haddad M, Gray R, Gournay K. Mental health nursing andphysical health care: a cross-sectional study of nurses' attitudes, practice,and perceived training needs for the physical health care of people withsevere mental illness. Int J Ment Health Nurs. 2013;22(5):409–17. https://doi.org/10.1111/j.1447-0349.2012.00883.x.
21. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items forsystematic reviews and meta-analyses: the PRISMA statement. PLoS Med.2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097.
22. Munn Z, Srtern C, Aromataris E, Lockwood C, Jordan Z. What kind ofsystematic review should I conduct? A proposed typology and guidance forsystematic reviewers in the medical and health sciences. BMC Med ResMethodol. 2018;18(5):1–9. https://doi.org/10.1186/s12874-017-0468-4.
23. Hardy S, White J, Deane K, Gray R. Educating healthcare professionals to acton the physical health needs of people with serious mental illness: asystematic search for evidence. J Psychiatr Ment Health Nurs. 2011;18(8):721–7. https://doi.org/10.1111/j.13652850.2011.01722.x.
24. Bland AJ, Topping A, Wood B. A concept analysis of simulation as a learningstrategy in the education of undergraduate nursing students. Nurse EducToday. 2011;31:664–70. https://doi.org/10.1016/j.nedt.2010.10.013.
25. Thomas BH, Ciliska D, Dobbins M, Micucci S. A process for systematicallyreviewing the literature: providing the research evidence for public healthnursing interventions. Worldviews Evid-Based Nurs. 2004;1(3):176–84. https://doi.org/10.1111/j.1524-475X.2004.04006.x.
26. NIH National Heart, Lung and Blood Institute (n.d.). Study QualityAssessment Tools: Quality Assessment Tool for Observational Cohort andCross Sectional Studies. Accessed 28 Apr 2018: https://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/tools
27. Critical Appraisal Skills Programme (n.d.). CASP checklist: 10 questions tohelp you make sense of qualitative research. Oxford: CASP. Available at:https://casp-uk.net/wp-content/uploads/2018/01/CASP-Qualitative-Checklist-2018.pdf. Accessed 16 Apr 2019.
28. Campbell MJ. Statistics at square one (9th edition) T.D.V. Swinscow [revisedby M.J. Campbell]: University of Southampton: BMJ publishing group; 1997.Accessed 14 Jun 2018: https://www.bmj.com/about-bmj/resources-readers/publications/statistics-square-one/
29. Wilson, D.B. (n.d.). Practical meta-analysis effect size calculator. Accessed 11Mar 2019 https://campbellcollaboration.org/escalc/html/EffectSizeCalculator-SMD-main.php .
30. Happell B, Platania-Phung C, Scott D. Are nurses in mental health servicesproviding physical health care for people with serious mental illness? AnAustralian perspective. Issues Ment Health Nurs. 2013;34(3):198–207. https://doi.org/10.3109/01612840.2012.733907.
Dickens et al. BMC Nursing (2019) 18:16 Page 19 of 21
31. Happell B, Platania-Phung C, Scott D. Physical health care for people withmental illness: training needs for nurses. Nurse Educ Today. 2013;33:396–401. https://doi.org/10.1016/j.nedt.2013.01.015.
32. Happell B, Platania-Phung C, Scott D. Proposed nurse-led initiatives inimproving physical health of people with serious mental illness: a survey ofnurses in mental health. J Clin Nurs. 2013;23:1018–29. https://doi.org/10.1111/jocn.12371.
33. Happell B, Platania-Phung C, Scott D, Nankivell J. Communication withcolleagues: frequency of collaboration regarding physical health ofconsumers with mental illness. Perspect Psychiatr Care. 2014;50(1):33–43.https://doi.org/10.1111/ppc.12021.
34. Happell B, Platania-Phung C, Scott D. What determines whether nursesprovide physical health care to consumers with serious mental illness? ArchPsychiatr Nurs. 2014;28:87–93. https://doi.org/10.1016/j.apnu.2013.11.001.
35. Happell B, Platania-Phung C, Scott D, Stanton R. Predictors of nurse supportfor the introduction of the cardiometabolic health nurse in the Australianmental health sector. Perspect Psychiatr Care. 2015;51(3):162–70. https://doi.org/10.1111/ppc.12077.
36. Happell B, Platania-Phung C. Cardiovascular health promotion andconsumers with mental illness in Australia. Issues Ment Health Nurs. 2015;36:286–93. https://doi.org/10.3109/01612840.2014.981770.
37. Happell B, Platania-Phung C, Stanton R, Millar F. Exploring the views ofnurses on the cardiometabolic health nurse in mental health services inAustralia. Issues Ment Health Nurs. 2015;36:135–44. https://doi.org/10.3109/01612840.2014.901449.
38. Happell B, Platania-Phung C, Scott D, Hanley C. Access to dental care anddental ill-health of people with serious mental illness: views of nursesworking in mental health settings in Australia. Aust J Prim Health. 2015;21(1):32–7. https://doi.org/10.1071/PY13044.
39. Klein TA, Graves JM. A comparison of psychiatric and non-psychiatric nursepractitioner knowledge and management recommendations regardingadolescent mild traumatic brain injury. J Am Psychiatr Nurses Assoc. 2017;23(1):37–49. https://doi.org/10.1177/1078390316668992.
40. Clancy R, Lewin TJ, Bowman JA, Kelly BJ, Mullen AD, Flanagan K, HazeltonMJ. Providing physical health care for people accessing mental healthservices: clinicians’ perceptions of their role. Int J Ment Health Nurs. 2018;28(1):256–67. https://doi.org/10.1111/inm.12529.
41. Chee G, Wynaden D, Heslop K. The provision of physical health care bynurses to young people with first episode psychosis: a cross-sectional study.J Psychiatr Ment Health Nurs. 2018;25(7):411–22.
42. Ganiah AN, Al-Hussami M, Alhadidi M. Mental health nurses’ attitudes andpractice toward physical health care in Jordan. Community Ment Health J.2017;53(6):725–35. https://doi.org/10.1007/s10597-017-0143-6.
43. Haddad M, Llewellyn-Jones S, Yarnold S, Simpson A. Improving thephysical health of people with severe mental illness in a low secureforensic unit: an uncontrolled evaluation study of staff training andphysical health care plans. Int J Ment Health Nurs. 2016;25(6):554–65.https://doi.org/10.1111/inm.12246.
44. Wynaden D, Heslop B, Heslop K, Barr L, Lim E, Chee GL, Murdock J. Thechasm of care: where does the mental health nursing responsibility lie forthe physical health care of people with severe mental illness? Int J MentHealth Nurs. 2016;25(6):516–25. https://doi.org/10.1111/inm.12242.
45. Howard L, Gamble C. Supporting mental health nurses to address thephysical health needs of people with serious mental illness in acuteinpatient care settings. J Psychiatr Ment Health Nurs. 2010;18(2):105112.https://doi.org/10.1111/j.1365-2850.2010.01642.x.
46. Terry J, Cutter J. Does education improve mental health practitioners'confidence in meeting the physical health needs of mental health serviceusers? A mixed methods pilot study. Issues Ment Health Nurs. 2013;34(4):249–55. https://doi.org/10.3109/01612840.2012.740768.
47. Osborn S, Douglas C, Reid C, Jones L, Gardner G. The primacy of vital signs– acute care nurses’ and midwives’ use of physical assessment skills: a crosssectional study. Int J Nurs Stud. 2015;52:952–62 https://doi.org/10.1016/j.ijnurstu.2015.01.014.
48. Artzi-Medvedik R, Chertok IRA, Romem Y. Nurses' attitudes towards breastfeedingamong women with schizophrenia in southern Israel. J Psychiatr Ment HealthNurs. 19(8):702–8. https://doi.org/10.1111/j.1365-2850.2011.01846.x.
49. Hunter J, Rawlings-Anderson K, Lindsay T, Bowden T, Aitken LM. Exploringstudent nurses' attitudes towards those who are obese and whether theseattitudes change following a simulated activity. Nurse Educ Today. 2018;65:225–31. https://doi.org/10.1016/j.nedt.2018.03.013.
50. Magor-Blatch LE, Rugendyke AR. Going smoke-free: attitudes of mentalhealth professionals to policy change. J Psychiatr Ment Health Nurs. 2016;23(5):290–302. https://doi.org/10.1111/jpm.12309.
51. Sung SC, Jiang HH, Chen RR, Chao JK. Bridging the gap in sexual healthcarein nursing practice: implementing a sexual healthcare training programmeto improve outcomes. J Clin Nurs. 2016;25:19–20. https://doi.org/10.1111/jocn.13441 2989-3000.
52. Wynn SD. Improving the quality of care of veterans with diabetes: asimulation intervention for psychiatric nurses. J Psychosoc Nurs Ment HealthServ. 2011;49(2):38–45. https://doi.org/10.3928/02793695-20110111-01.
53. Brimblecombe N, Tingle A, Tunmore R, Murrells T. Implementing holisticpractices in mental health nursing: a national consultation. Int J Nurs Stud.2007;44(3):339–48. https://doi.org/10.1016/j.ijnurstu.2006.07.021.
54. Delaney KR, Hamera E, Drew BL. Health advanced practice nursing: theadequacy of educational preparation: voices of our graduates. J AmPsychiatr Nurses Assoc. 2009;15(6):383–92. https://doi.org/10.1177/1078390309353070.
55. Mwebe H. Physical health monitoring in mental health settings: a studyexploring mental health nurses' views of their role. J Clin Nurs. 2017;26(19/20):3067–78. https://doi.org/10.1111/jocn.13653.
56. Çelik Ince S, Partlak Günüşen N, Serçe Ö. The opinions of Turkish mentalhealth nurses on physical health care for individuals with mental illness: aqualitative study. J Psychiatr Ment Health Nurs. 2018;25(4):245–57.
57. Happell B, Stanton R, Hoey W, Scott D. Reduced ambivalence to the role ofthe cardiometabolic health nurse following a 6-month trial. PerspectPsychiatr Care. 2015;51(2):80–5. https://doi.org/10.1111/ppc.12066.
58. Sharp DL, Blaakman SW, Cole RE, Evinger JS. Report from a national tobaccodependence survey of psychiatric nurses. J Am Psychiatr Nurses Assoc.2009;15(3):172–81. https://doi.org/10.1177/1078390309336746.
59. Dorsay JP, Forchuk C. Assessment of the sexuality needs of individuals withpsychiatric disability. J Psychiatr Ment Health Nurs. 2009;1(2):93–7. https://doi.org/10.1111/j.1365-2850.1994.tb00025.x.
60. Quinn C, Platania-Phung C, Bale C, Happell B, Hughes E. Understanding thecurrent sexual health service provision for mental health consumers bynurses in mental health settings: findings from a survey in Australia andEngland. Int J Ment Health Nurs. 2018;27(5):1522–34. https://doi.org/10.1111/inm.12452.
61. Verhaege N, De Maeseneer J, Maes L, Van Heeringen C, Annemans L. Healthpromotion in mental health care: perceptions from patients and mental healthnurses. J Clin Nurs. 2013;22(11–12):1569–78. https://doi.org/10.1111/jocn.12076.
62. Johannessen B, Skagestad I, Bergkaasa AM. Food as medicine in psychiatriccare: which profession should be responsible for imparting knowledge anduse of omega-3 fatty acids in psychiatry. Complement Ther Clin Pract. 2011;17(2):107–12. https://doi.org/10.1016/j.ctcp.2010.08.001.
63. Hughes E, Gray R. HIV prevention for people with serious mental illness: asurvey of mental health workers' attitudes, knowledge and practice. J ClinNurs. 2009;18(4):591–600. https://doi.org/10.1111/j.1365-2702.2007.02227.x.
64. Sharma R, Meurk C, Bell S, Ford P, Gartner C. Australian mental health carepractitioners’ practices and attitudes for encouraging smoking cessationand tobacco harm reduction in smokers with severe mental illness. Int JMent Health Nurs. 2018;27:247–57. https://doi.org/10.1111/inm.12314.
65. Parel JT, Khakha DC, Balhara YPS. Do psychiatric nurses have favourableknowledge and attitude towards tobacco prevention among their patients?A cross-sectional study from national capital of India. Asian J Nurs Educ Res.2018;8(1):01–4. https://doi.org/10.5958/2349-2996.2018.00001.0.
66. Fernando A, Attoe C, Jaye P, Cross S, Pathan J, Wessely S. Improvinginterprofessional approaches to physical and psychiatric comorbiditiesthrough simulation. Clin Simul Nurs. 2017;13(4):186193. https://doi.org/10.1016/j.ecns.2016.12.004.
67. White J, Hemingway S, Stephenson J. Training mental health nurses toassess the physical health needs of mental health service users: a pre- andpost-test analysis. Perspect Psychiatr Care. 2014;50(4):243–50. https://doi.org/10.1111/ppc.12048.
68. Hemingway S, Clifton A, Stephenson J, Edward KL. Facilitating knowledge ofmental health nurses to undertake physical health interventions: a pre-test/post-test evaluation. J Nurs Manag. 2014;22(3):383–93. https://doi.org/10.1111/jonm.12220.
69. Hemingway S, Stephenson J, Trotter F, Clifton A, Holdich P. Increasing thehealth literacy of learning disability and mental health nurses in physicalcare skills: a pre and post-test evaluation of a workshop on diabetes care.Nurse Educ Pract. 2015;15(1):30–7. https://doi.org/10.1016/j.nepr.2014.08.003.
Dickens et al. BMC Nursing (2019) 18:16 Page 20 of 21
70. Hemingway S, Trotter F, Stephenson J, Holdich P. Diabetes: Increasing theknowledge base of mental health nurses. Br J Nurs. 2013;22(17):991–5.https://doi.org/10.12968/bjon.2013.22.17.991.
71. Nash M. Physical care skills: a training needs analysis of inpatient andcommunity mental health nurses. Ment Health Pract. 2005;9(4):20–3. https://doi.org/10.7748/mhp2005.12.9.4.20.c1896.
72. Happell B, Scott D, Nankivell J, Platania-Phung C. Nurses’ views on trainingneeds to increase provision of primary care for consumers with seriousmental illness. Perspect Psychiatr Care. 2013;49:210–7. https://doi.org/10.1111/j.1744-6163.2012.00351.x.
73. Happell B, Scott D, Nankivell J, Platania-Phung C. Screening physicalhealth? Yes! But…: nurses’ views on physical health screening inmental health care. J Clin Nurs. 2013;22:2286–97. https://doi.org/10.1111/j.1365-2702.2012.04325.x.
74. Birks M, Cant R, James A, Chung C, Davis J. The use of physical assessmentskills by registered nurses in Australia: issues for nursing education.Collegian. 2012;20:27–33. https://doi.org/10.1016/j.colegn.2012.02.004.
75. Giddens JF. A survey of physical assessment techniques performed by RNs:lessons for nursing education. J Nurs Educ. 2007;46:83–7.
76. Douglas C, Osborne S, Reid C, Batch M, Hollingdrake O, Gardner G. Whatfactors influence nurses’ assessment practices? Development of the barriersto nurses’ use of physical assessment scale. J Adv Nurs. 2014;70:2683–94.https://doi.org/10.1111/jan.12408.
77. Phelan M, Stradins L, Amin D, Isadore R, Hitrov C, Doyle A, Inglis R. Thephysical health check: a tool for mental health workers. J Ment Health. 2004;13(3):277–85. https://doi.org/10.1080/09638230410001700907.
78. Shuel F, White J, Jones M, Gray R. Using the serious mental illness healthimprovement profile [HIP] to identify physical problems in a cohort ofcommunity patients: a pragmatic case series evaluation. Int J Nurs Stud.2010;47(2):136–45. https://doi.org/10.1016/j.ijnurstu.2009.06.003.
79. Freed GL, Clark SJ, Sorensen J, Lohr JA, Cefalo R, Curtis P. Nationalassessment of physicians’ breastfeeding knowledge, attitudes, training, andexperience. JAMA. 1995;273:472–6.
80. Corrigan P, Markowitz FE, Watson A, Rowan D, Kubiak MA. An attributionmodel of public discrimination towards persons with mental illness. JHealth Soc Behav. 2003;44(2):162–79.
81. Shore TH, Tashchian A, Adams JS. Development and validation of a scalemeasuring attitudes toward smoking. J Soc Psychol. 2000;140(5):615–23.
82. Nash M. Mental health nurses' diabetes care skills - a training needs analysis. BrJ Nurs. 2009;18(10):626–30. https://doi.org/10.12968/bjon.2009.18.10.42472.
83. Quinn C, Happell B, Browne G. Opportunity lost? Psychiatric medicationsand problems with sexual function: a role for nurses in mental health. J ClinNurs. 2011;21:415–23. https://doi.org/10.1111/j.1365-2702.2011.03908.x.
84. Ford P, Tran P, Keen B, Gartner C. Survey of Australian oral health practitionersand their smoking cessation practices. Aust Dent J. 2015;60:43–51.
85. Morris C, Waxmonsky J, May M, Giese A, Martin L. Smoking cessation forpersons with mental illness: a toolkit for mental health providers: Universitypf Colorado Denver, CO; 2009. Accessed 19 Mar 2019: https://www.integration.samhsa.gov/Smoking_Cessation_for_Persons_with_MI.pdf
86. Watson L, Oberle K, Deutscher D. Development and psychometric testing ofthe Nurses' attitudes toward obesity and obese patients scale (NATOOPS).Res Nurs Health. 2008;31(6):586–93. https://doi.org/10.1002/nur.20292.
87. Lasater K. Clinical judgment development: using simulation to create anassessment rubric. J Nurs Educ. 2007;46(11):496–503. https://doi.org/10.1097/NND.0000000000000209.
Dickens et al. BMC Nursing (2019) 18:16 Page 21 of 21
