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Mental Health Work In The Community Theory And Practice In Social Work And Community Psychiatric Nursing 1st edition By Michael Sheppard 9781850009795 1850009791
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Para mi familia, mi mujer Maite, y mis hijos Ruben, Érin y Jorge. Con todo mi amor.
and acronyms
1An introduction to physical health in mental illness1
2An introduction to key concepts in measuring health and illness14
3Clinical skills for physical assessment in mental health settings26
4Principles of physical health assessment in mental health care61
7Assessing nutrition, diet and physical activity126
8Medication, adverse drug reactions and physical health151
9Physical health emergencies in mental health settings174
10Practical steps in improving the physical health of people with severe mental illness191
About the author
Michael Nash is lecturer in psychiatric nursing at Trinity College Dublin. His career began in Gransha Hospital, Derry City before moving to London via a few years in the Channel Islands. In London he worked at various levels in both the NHS and private health care sectors. He studied at the University of North London where he obtained a BSc (Hons) in Health Studies then at St George’s Medical School, University of London where he eventually obtained an MSc in Health Sciences. He moved into higher education spending happy years at London Metropolitan University where he obtained a Post-graduate Certificate in Learning and Teaching before moving to Middlesex University. At Middlesex he commenced a professional doctorate that is nearing completion and has retained many good friendships from very happy times there.
Acknowledgements
I would like to thank some colleagues and friends who have helped me through the process of writing this book. First to Nicky Torrance, Jeff Sapiro and Sheila Fawell at Middlesex University, London who gave me the time and space necessary to develop the ideas for the book. To Janet Holmshaw, also at Middlesex, for her support and encouragement during the long process of writing; it was much appreciated. I would also like to thank Professor Agnes Higgins at Trinity College Dublin for her support and understanding when finishing the book.
I would also like to thank those who gave me permission to reproduce their valued work in this book.
Finally, thanks to Rachel for her kind comments and support throughout the lengthy writing and editing process, we got there – eventually.
Abbreviations and acronyms
ABGSarterial blood gases
ADRadverse drug reaction
BHFBritish Heart Foundation
BLSbasic life support
BMIbody mass index
BNFBritish National Formulary
BPblood pressure
CAcardiac arrest
CCUcoronary care unit
CHDcoronary heart disease
CMHNcommunity mental health nurse
COPDchronic obstructive pulmonary disease
CPAcare programme approach
CNScentral nervous system
DHDepartment of Health
DKAdiabetic ketoacidosis
DRCDisability Rights Commission
DSMIVDiagnostic and Statistical Manual IV
ECGelectrocardiogram
ECTelectro-convulsive therapy
FBCfull blood count
HDLshigh density lipoproteins
HEhealth education
HNAhealth needs assessment
HPhealth promotion
HPAHealth Protection Agency
ICD10International Classification of Diseases 10
IoHInequalities of Health
IRincidence rate
LDLslow density lipoproteins
LElife expectancy
MAOIsmonoamine oxidase inhibitors
MHNmental health nurse
MRmortality rate
NICENational Institute of Health and Clinical Excellence
NMCNursing and Midwifery Council
NMSneuroleptic malignant syndrome
NRTnicotine replacement therapy
NSFNational Service Framework
OHorthostatic hypotension
OPDMOffice of the Deputy Prime Minister
OToccupational therapist
Abbreviations and acronyms
PEFRpeak expiratory flow rate
PRprevalence rate
RTrapid tranquilisation
SMARTspecific, measurable, attainable, realistic and timely
SMIsevere mental illness
SMRstandardized mortality ratio
SSserotonin syndrome
SSRIsselective serotonin reuptake inhibitors
STDsexually transmitted disease
T2Dtype 2 diabetes
TNAtraining needs analysis
WCCwhite cell count
WHOWorld Health Organization
An introduction to physical health in mental illness
By the end of this chapter you should be able to:
• Define health and health beliefs and illustrate why these are important to clients
• Appreciate the impact of physical illness on our clients
• Identify factors that negatively impact on the physical health of our clients
• Be aware of barriers to physical care of our clients
Box1.1 Exercise health problems you encounter.
Describe the physical health status of your client group. List the most common physical
Physical well-being is important to all of us whether we have a mental health problem or not. Indeed the physical health needs of our clients mirror those of the general population. Physical health of clients has become more prominent in mental health policy and practice arenas. After seemingly years of neglect it became apparent that the physical health of clients under the care of mental health services was not only poor but a largely unaddressed area of need. Nash (2005) suggests that this lack of focus on physical health compromises the notion of holistic care in mental health practice. Therefore physical health must be embraced as part of a holistic assessment that includes social, emotional, economic and psychological needs.
What do we know about physical health in people with severe mental illness?
The focus of this book is the specific issues related to people with a primary mental health problem and a secondary physical problem, e.g. schizophrenia and diabetes. However, we should remain aware that there are issues relating to individuals with a primary physical condition and a secondary mental health problem. The World Health Organization (WHO 2003) suggests high prevalence of co-morbid depression in a range of physical illnesses, for example, depression in hypertension is up to 29 per cent, in cancer up to 33 per cent, in HIV/AIDS up to 44 per cent and in TB up to 46 per cent. This is something community practitioners should be aware of in respect to mental health promotion (MHP) in primary care. Poor physical health affects our mental well-being while mental illness increases mortality and morbidity. A combination of both can impair the rate or fullness of recovery. Research has
2 Physical health and well-being in mental health nursing
consistently shown that the physical health of people with severe mental illness is frequently poor (Phelan et al. 2001). This is evidenced by the following:
• There are higher Standardized Mortality Ratios (SMRs) for cardiovascular disease, deaths due to infections and deaths from respiratory disorders (Harris and Barraclough 1998).
• There exists a higher risk of preventable death, with Farnam et al. (1999) estimating that people with mental illness die between 10 and 15 years earlier than the general population.
• People with bipolar disorder and diabetes have a 50 per cent higher risk of dying than someone with diabetes who does not have a mental illness (DRC 2006).
• People with schizophrenia may be at increased risk for Type 2 diabetes because of the side effects of medication, poorer healthcare, poor physical health and less healthy lifestyles (Dixon et al. 2000).
• In the UK 62 per cent of people with a psychotic disorder reported themselves as having a long-standing physical complaint as compared to 42 per cent with no psychotic disorder (Singleton et al. 2000).
The irony is that in many instances these statistics refer to current service users, in contact with either teams of health and social care professionals, or primary care services. We must therefore ask ourselves how can such severe and chronic physical illness be so prevalent in our client group and yet go undetected? This is not just a question for specialist mental health services. It is also a question for primary care services where, in the UK, people with mental health problems have 13 to 14 consultations with their GP per year (Mentality and NIMHE 2004) yet severe and chronic physical conditions are underdiagnosed.
Concerns regarding poor physical health in mental health are not confined to the UK, it is an international problem. For example, in Western Australia Lawrence et al. (2001) found that clients died between 1.3 and 5.4 times more than the general population, for all major natural causes of death while in the USA Parks et al. (2006) found clients die on average 25 years earlier than the general population.
What is health?
Box1.2
How would you define (a) health and (b) illness? Which models might influence your
Exercise definitions e.g. medical, social or psychological?
It is over fifty years since the World Health Organization (WHO) was established and the most often cited definition of health originates from them. The WHO (1948) defines health as ‘a state of complete physical, mental and social well being and not merely the absence of disease or infirmity’. Saracci (1997) suggests that this is more a definition of happiness than health. He cites an anecdote from Sigmund Freud who, on having to stop smoking for health reasons, wrote ‘I am now better than I was, but not happier.’
The WHO definition is certainly one to aspire to but it does not appear entirely holistic. It is a twentieth century definition in a twenty-first century world and omits other factors that are now deemed important for positive health, for example, emotional, environmental and spiritual factors – however, the ‘social’ aspect might encompass these. In developing the National Aboriginal Mental Health Policy and Plan, Swan and Raphael (1995) found that Aboriginal concepts of mental health are holistic being defined as: ‘health does not just mean the physical well-being of the individual but refers to the social, emotional and cultural well-being of the whole community’.
Defining health is problematic as individual experiences of health and illness will rarely be the same. Health, and indeed, illness are inherently individualized concepts. For example, have you ever gone to work sick? Why? Maybe you felt that you could struggle on, maybe you didn’t want the hassle of reporting sick. Nevertheless through a process of rationalization we may underestimate our levels of illness by saying ‘it’s only a cold’ in order to undertake our other social roles. Similarly we may diminish our own ill health, or have our ill health diminished by others through comparison to other people, e.g. ‘at least it’s not cancer’
Another way to explore the question ‘what is health?’ may be to look at what can make us unhealthy or ill. However, again this is controversial as being labelled unhealthy or ill can be stigmatizing and disempowering. Despite being problematic, defining health is important for developing public health strategy, models of health care delivery and diagnosing illness. Being complex to define, we might suggest that holistic definitions of health based on multidimensional models would be best for exploring both risk factors and protective factors for physical illness.
Blaxter (1990) explored the concept of health by surveying 9000 individuals and asking the following questions: (i) Think of someone you know who is very healthy; who are you thinking of? How old are they and what makes you call them healthy? (ii) At times people are healthier than at other times. What is it like when you are healthy? Ten categories of health and the characteristics that typified the responses are outlined in Table 1.1.
Health beliefs
There will always be a tension between what professionals and the public believe about concepts of health and illness. The health beliefs of the general public will influence their helpseeking behaviour and the health beliefs of professionals influence the types of interventions and services they provide. Indeed health beliefs may vary between cultures, for example, the mind–body split that occurs in Western medicine.
One aspect of mental health that can complicate our understanding of clients’ health beliefs is the concept of insight. Insight is a frequently used descriptor in mental health. There is no uniform definition of insight as it is not a black and white issue and commonly used descriptors
Table 1.1 Ten categories of health and the characteristics that typified the responses
Health categoryCharacteristic
1Negative answersHealth not rated highly as a virtue, a lack of concern for healthy behaviour
2Health as not illBeing symptom free, never seeing a doctor
3Health as absence of disease/ health despite disease
Did not have any really serious illness, ‘I am healthy although I do have diabetes’
4Health as a reserveThe ability to recover quickly
5Health as behaviour, as the healthy lifeHealth defined as ‘virtuous’ behaviour – being a non-smoker or non-drinker
6Health as physical fitnessBeing athletic or sporty, also for women having a good outward appearance
7Health as energy, vitalityHaving ‘get up and go’
8Health as a social relationshipHealth defined as having good relationships with others –especially for women
9Health as a functionBeing able to do things with less stress
10Health as psychosocial well-beingHealth as a state of mind
include: lacks insight; partial insight; insightless or; has insight. These measures are rather vague and do little to enhance our understanding or knowledge of insight. This may limit its therapeutic value. We may not know what insight is, but we know when it is not there. Although frequently used in relation to schizophrenia, insight is not a diagnostic category for schizophrenia in the International Classification of Disease 10 (ICD 10).
Having insight means that a person is aware that they are ill, that they need to get help and accept treatment. Gelder et al. (1996: 23) define insight as ‘awareness of ones own medical condition’. When someone does not have insight they do not recognize they are ill or that they need treatment. Amador (2001) approaches insight in neurological terms – anosognosia –meaning ‘unawareness of illness’, while David (1990) proposes that insight is composed of three distinct, overlapping dimensions, namely, the recognition that one has a mental illness, compliance with treatment, and the ability to re-label, or attribute, unusual mental events (e.g. delusions and hallucinations) as pathological.
Box1.3 Case example
Farlo has a 20 year history of schizophrenia. He presents with two main psychotic symptoms – auditory hallucinations and delusions of grandeur. He refuses to accept treatment, maintaining he is not sick. This is confirmed by TV news reports which say he is doing well. ‘How can I the great, supreme and magical Farlo be unwell?’ he asks the team at the ward round. Farlo currently lacks insight as (a) he is unaware that he is unwell; (b) he does not see the need for treatment; and (c) he does not attribute his psychotic symptoms to a mental illness.
Health beliefs, on the other hand, are our individually held beliefs about our own health and illness status – what causes us to be healthy, what may cause us to be ill, what we must do to stay well or what we must do in order to recover. While these are individual they have also been found to be social as they can be influenced by social factors such as culture (Herzlich 1973). A recurring problem with health beliefs is that clients may not share these with health providers or, in the case of smoking, they share the view that smoking is dangerous but continue to smoke. This clash of beliefs can be very challenging to the development and maintenance of therapeutic relationships, especially in mental health care with the added complexity of insight.
Linden and Godemann (2005) in a study of 364 schizophrenic outpatients assessed lack of insight and health beliefs and found these to be independent of each other. This meant that insight was related to their illness and health beliefs were related to personal life experiences. Although both concepts are associated with patient non-compliance, Linden and Godemann state that they are ‘separate clinical phenomena’ and as such this distinction should be made. This means that practitioners should not attribute poor lifestyle choices to a lack of insight. It is important for practitioners to know and understand the health beliefs of clients in order to better implement health education (HE) and health promotion interventions. It is also important not to conflate health beliefs with insight as health beliefs will influence responses to health and also the therapeutic nurse-patient relationship.
Box1.4 Case example
Ruari has a ten year history of schizo-affective disorder. He is currently in hospital due to a relapse caused by non-compliance with antipsychotic medications. Ruari also has a
history of asthma and uses a bronchodilator. At medication rounds he willingly accepts his asthma medication but staff need to continually prompt and encourage him to take his antipsychotic medication. When he is asked why he takes one medication and not the other Ruari replies ‘I have asthma and need my puffer to help me breathe. I even cut down on my smoking. But everyone tells me I’m mentally ill and I need to take the other tablets, but I don’t feel sick. Mentally I feel fine.’
Ruari is unaware that he has a mental illness as he appears to lack insight. Yet Ruari’s health beliefs indicate that he is aware of the need to take asthma medication and that he has even reduced his smoking. His health beliefs seem to be in conflict with insight. However, we must not conflate these as they are separate factors in health and illness. What practitioners need to do is use Ruari’s health beliefs about his asthma as a metaphor for his mental illness – the need to take treatment and keep taking it. Ruari may then accept that he requires antipsychotic medication to keep him well, just as he requires his bronchodilator for his asthma.
Physical illness will seldom be caused by one factor, rather it will be an interaction of many risk factors. The challenge for practitioners is to have the knowledge of the risk factors and skills to assess – either for screening or further investigation – using appropriate clinical skills and techniques. However, a further challenge for us is being able to implement the same process across a range of physical conditions prevalent in our clients, e.g. obesity or diabetes.
Factors that influence physical health in people with mental illness
The UK government states the reality of health inequality very clearly when it says ‘the poorer you are, the more likely you are to be ill and to die younger’ (DH 1999a). This is truer for our clients in a range of physical conditions. However, the government still places some emphasis on the individual’s responsibility for improving their own health through physical activity, an improved diet and quitting smoking (DH 1999a). Therefore, while health beliefs play an important role in our decision making, there are three important influences on the physical health of clients:
• Lifestyle factors
• Social factors
• Adverse drug reactions
The impact of lifestyle factors on the physical health of clients
The lifestyle choices we make can directly impact, positively or negatively, on our health. If someone smokes they face an increased risk of ill health or if they exercise and eat healthily they reduce the risk of ill health. Our clients are often exposed to adverse lifestyle choices for example:
• Smoking prevalence is significantly higher among people with mental health problems than the general population. Some studies show rates as high as 80 per cent among people with schizophrenia (McNeill 2001).
• Kendrick (1996) found that of 101 people with SMI living in the community 26 were clinically obese.
• McCreadie et al. (1998) found that people with schizophrenia made poor dietary choices characterized by a high fat, low fibre dietary intake.
• Lifestyle factors that cause obesity, such as low levels of exercise and poor diet, are present in people with mental illness (Brown et al. 1999).
The outcomes of unhealthy lifestyle choices are increased risk of developing severe and chronic long term physical conditions such as type two diabetes, coronary heart disease (CHD), stroke or smoking related respiratory disorders. However, people need to be fully informed about the risks of making unhealthy decisions and research shows that clients seldom receive the same health promotion advice or interventions as the general population (Burns and Cohen 1998). The result is a double whammy of an SMI and a chronic physical problem which can serve to exclude clients from employment or educational opportunities where they may be too ill to avail themselves of these.
How can social factors influence the physical health of our clients?
Having a diagnosis of mental illness negatively impacts on the client’s socio-economic circumstances. A UK government report The Social and Economic Circumstances of Adults with Mental Disorders (Meltzer et al. 2002) found the following:
• Compared with all other groups, those with a psychotic disorder were more likely to have left school before reaching 16 years of age, without qualifications.
• About 60 per cent of the sample assessed as having a psychotic disorder lived in a household with an income less than £300 a week compared with 37 per cent of those with a current neurotic disorder and 28 per cent with no mental disorder.
• Those with a mental disorder were far more likely than those with no disorder to be living in rented accommodation (38 per cent compared with 24 per cent).
• Three of these six specified life events were twice as likely to have been experienced by those with a mental disorder compared with those with no mental disorder: separation or divorce (44 per cent compared with 23 per cent); serious injury, illness or assault (40 per cent compared with 22 per cent); and having a serious problem with a close friend or relative (27 per cent compared with 13 per cent).
Determinants of health
Wanless (2004) suggests that health and well-being are influenced by many factors including past and present behaviour, healthcare provision and ‘wider determinants’ including social, cultural and environmental factors. While it is accepted that lifestyle factors are important in determining physical health, practitioners should not overlook other important factors such as social class.
People living in the poorest part of society will be more exposed to determinants of ill health, especially those living in inner city areas where there is an increased exposure to poverty, social deprivation and social exclusion. Typically these neighbourhoods have poor housing, few leisure amenities, higher levels of unemployment and increased crime or the threat of crime and reduced access to education and low educational attainment, for example, more school expulsions.
The UK government recognizes that health inequality is widespread and the most disadvantaged have suffered most from poor health (DH 1999a). Therefore while this type of environment
is not conducive to good health, it is the type of environment where many of our clients will come from. This should prompt us to be more aware of the influence of social factors on physical health.
Inequalities in health
While lifestyle factors offer a biological explanation of health and illness, the social model can offer us alternative explanations. One important factor in the health of any population is Inequalities of Health (IoH). Acheson (1998) contends that where IoH exist we can see great differences in health status in social classes when using occupation as a measurement. This is illustrated by health gradients where those in lower social classes tend to have poorer health (increased morbidity) and poorer health outcomes (increased mortality). The UK Department of Health (2008a) states that health inequalities are the result of a complex and wide-ranging network of factors such as material disadvantage, poor housing, lower educational attainment, insecure employment or homelessness. People exposed to IoH have poorer health outcomes and an earlier death compared with the rest of the population.
Our clients are a socially disenfranchised group, often excluded from the fundamental aspects of society (Nash 2002). Therefore an alternative explanation for a client’s poor physical health is their position in the social hierarchy. Coming from the lowest social class they face greater morbidity and mortality than those from higher social classes. This offers us an alternative explanation to lifestyle factors. Figures 1.1 and 1.2 illustrate the class gradient in respect to death rates in general (Figure 1.1) and deaths by suicide (Figure 1.2).
Social class and mental illness
People with mental health problems are often over represented in the lower social classes. Those with psychotic disorders are more likely to be of a lower social class (see Table 1.2). The Public Health Agency of Canada (2002) nicely illustrates two theories for this:
Figure 1.1 Social class and mortality
Source: (DH 1999a)
Figure 1.2 Social class and suicide: men aged 20–64, England 1997
Source: DH (2002a)
Table 1.2 Social class and mental illness
Psychotic disorderNo psychotic disorder
Social Class IV or V 39%22%
Economically Inactive 70%30%
Source: Office of National Statistics (2000)
•‘Social drift’: this theory suggests that individuals who are predisposed to mental illness have lower than expected educational and occupational attainment and therefore ‘drift’ down the socio-economic ladder.
•‘Social causation’: this theory suggests that social experiences of members of different socioeconomic groups influence the likelihood of becoming mentally ill, e.g. members of lower social classes are subjected to greater stress as a result of deprivation and are forced to cope with elevated stress levels with limited resources.
Social class can affect the prevalence of mental health problems. Here we can see the part that poverty and deprivation has in influencing the physical and mental health of socially excluded groups. Therefore the challenge to practitioners is clear. The majority of our client group will come from a backdrop of adverse social conditions with experiences of poverty and deprivation. We should therefore be aware that there is a strong likelihood that our clients from this group will have a physical health condition that may be undiagnosed or may be at risk of developing one.
Poverty
Mental illness seldom discriminates between class, gender or ethnicity and the WHO (2003: 7) states that no group is immune to mental disorders, but the risk is higher among the poor, the homeless, the unemployed and persons with low education. Poverty is an important factor in physical and mental ill health. In Ireland a report by Walsh and Daly (2004) suggested that social class divisions indicate that poverty and disadvantage are contributory factors, both to the incidence and prevalence of mental illness. In the UK a survey by Focus on Mental Health (2001) found that clients suffered significant poverty as a result of not being able to get work. It also asked clients about their experiences of living on a low income and found the following:
• 66 per cent of respondents had difficulties making their income last for a week.
• 81 per cent of respondents thought that mental health problems increased the likelihood of being on low income.
• 50 per cent of respondents said that their financial situation meant they were excluded from their community.
Employment
Employment is seen as a way out of poverty. Being in work increases our quality of life through material wealth and economic productivity. Employment can also increase our self-worth and self-esteem and it can protect us against social exclusion. Employment is a key priority for clients and a key component of recovery. However, research shows that only around 20 per cent of people with mental health problems are in employment (DRC 2006), while the Social Exclusion Unit (2004) found that mental health problems are more likely to be listed on GP sickness certificates in the most deprived areas of the country.
Clients frequently encounter discrimination and negative, stereotypical attitudes among employers. Research by the DRC (2003) found that only around 37 per cent of employers are willing to take on someone with a mental health problem while the Social Exclusion Unit found clients experience stigma as a barrier to employment (ODPM 2004).
Lacking employment opportunities means that our clients depend on social welfare benefits. This places them in the lowest income group, which the UK government recognizes is clearly linked to ill health (DH 1999a). Therefore, while clients battle established stigma and discrimination, they may be doing so in a state of poor physical health. This may constitute another barrier to gainful employment as clients want to work but are physically unable to. These social factors tend to snowball and trap clients in a vicious cycle of poverty and deprivation. This increases their risk of social exclusion and poor health outcomes.
Social inclusion and social exclusion
The preceding parts of this chapter serve to build up a picture of how social factors can influence the health of clients and their inclusion or exclusion. Social inclusion is defined as ‘a virtuous circle of improved rights of access to the social and economic world, new opportunities, recovery of status and meaning and reduced impact of disability’ (Sayce 2001: 122). To be included in society means to be accepted as ‘one of us’, enabling easier access to healthcare services or employment. However, all too often clients are seen as ‘one of them’ – as outside of society – and face social exclusion. Sayce (2000) defines social exclusion as ‘the interlocking and mutually compounding problems of impairment, discrimination, diminished social role, lack of economic and social participation and disability’. Social exclusion often results in decreased social networks, including healthcare networks, which can further exacerbate both mental and physical health problems.
Adverse drug reactions
While this will be covered in detail in Chapter 8, it is worth briefly mentioning this issue here. Iatrogenic illness, illness caused by adverse drug reactions, contributes to physical ill health in our clients. Anti-psychotic medication has side effects that can lead to obesity, increased risk of developing type 2 diabetes and cardiac problems. This is quite different from lifestyle or social factors as it is a risk factor unique to our clients. Members of the general population will not be exposed to this risk factor.
10 Physical health and well-being in mental health nursing
So far we have examined factors that influence the physical health of our clients. These factors will seldom be stand alone and most probably will be interlinked. Poor lifestyle can naturally increase the risk of ill health but lifestyle choices may be restricted by social factors such as social class, inequalities in health and social exclusion. Adverse drug reactions also increase the risk of physical illness for clients. However, there is a final piece of the puzzle of factors that can increase physical illness in clients and we will now explore this.
Box1.6
Revisit your answer to exercise three above. Which other factors can act as barriers to
Exercise physical health care in your client group?
Barriers to physical health care for clients
By far one of the most problematic areas of mental health care is stigma. In the 2007 Attitudes to Mental Illness survey for the UK Department of Health (TNS 2007) there was an overall decrease in positive attitudes towards people with mental illness since 1994. This may be due to the frequency of reports into incidents involving people with mental illness in the community during this period and how these were reported in the media.
However, having negative attitudes about people with mental illness is not confined to the general public. Research shows that health professionals, including those in mental health care, can harbour stereotypical or stigmatizing views towards clients. For example in a survey of clients by Mind (1996) one third felt that their GP had treated them unfairly due to their mental illness. With respect to mental health professionals Lewis and Appleby (1988) found that psychiatrists had negative attitudes towards personality disorder finding this client group less deserving of care, manipulative, attention seeking and annoying. In a study of 65 qualified mental health nurses (MHNs) working in both inpatient and community services, Deans and Meocevic (2006) observed that the majority of them found people with borderline personality disorder manipulative with some having negative attitudes towards this client group.
Stigma often prevents people from seeking help to the extent that, when they do, their condition may have significantly worsened. This view is supported by Ward (1997) who found that negative media reporting can negatively impact on an individual’s help-seeking behaviour. Yamey (1999) reports the case of a psychiatrist, who during the course of a ward round found that two thirds (four out of six) patients had been struck off their GP’s list since admission. Following a further audit of 50 patients it was found that 30 per cent had been removed from their GP’s list at some point. This prompted a suspicion that some behavioural and psychiatric disorders could be construed as a reason for being excluded from GP lists.
Healthcare professionals’ attitudes
There are some myths and stereotypes surrounding physical health in clients which need to be dispelled in order for progress to be made. We can rightly speculate that having negative and stereotypical views of clients will have an impact in the way that care is provided to, or for, them. This is especially true of physical health care where at times practitioners may have a therapeutic fatalism, for example, ‘it’s no good trying to get them to stop smoking, they have been doing it for years’. Research by Dean et al. (2001) and Meddings and Perkins (2002) shows a prevailing assumption among mental health practitioners that clients are not interested in their physical health when, in fact, they are. This was typified with responses such as ‘people have more to worry about (in relation to smoking cessation)’.
Elsewhere it has been reported that some clients report ‘inappropriate stereotyping, negative attitudes and detrimental assumptions about the quality of life of people with mental illness’ (Nocon and Sayce 2006: 109), while the DRC (2006) found that individual experiences of primary care included reception staff with ‘bad’ attitudes, clients feeling that their physical symptoms were attributed to their mental illness and a perception of a lack of attention to problems.
Diagnostic overshadowing
As far back as 1979 Koranyi found that major medical illnesses went undiagnosed with clients’ physical complaints being labelled as ‘psychosomatic’. This process is known as diagnostic overshadowing (DO). DO is essentially a judgement bias, where a physical complaint or symptoms are put down to the mental illness rather than a genuine physical illness.
Box1.7 Case example
Brian is a 38-year-old male with a 20-year history of paranoid schizophrenia. He has periods of non-compliance with medication and is currently on olanzapine 20 mg BD. He frequently drinks alcohol, but not illicit substances and smokes up to 40 cigarettes daily. He does not exercise and recognizes that his diet is very poor. Brian tells his nurse that he has abdominal pains, saying ‘I feel something is growing inside my stomach’. His nurse puts this down to a nihilistic delusion and encourages Brian to continue taking his anti-psychotic medications.
This sounds entirely plausible and the nurse has acted on the presenting clinical picture. However, the likelihood of a physical complaint has been overlooked due to the history of mental illness (DO). Of course people with schizophrenia can have delusions like this but recent evidence from the DRC (2006) shows that people with schizophrenia are 90 per cent more likely –i.e. nearly twice as likely – to get bowel cancer, which is the second most common cause of cancer death in Britain. Therefore what is considered a delusion here may well be a severe physical complaint that needs investigation. We cannot second guess that the investigations might reinforce the delusion without first ruling out a primary physical cause. Delays like this may place Brian at risk of more serious illness, which when finally diagnosed might require radical surgery. If it turns out to be a delusion then we can begin interventions designed to reduce the impact of this.
Lack of policy guidance on responsibilities for clients’ physical health
This is not, strictly speaking, true. The UK National Service Framework Mental Health (DH 1999b) advocates the monitoring of physical health of clients both in mental health and primary care services. There are also physical monitoring guidelines attached to the National Institute of Health and Clinical Excellence (NICE) guidelines for bipolar disorder (NICE 2006) and schizophrenia (NICE 2009) respectively. However, there are other National Service Frameworks, for example, coronary heart disease (DH 2000a) or diabetes (DH 2001b) which have population health targets to be reached. How well these have been used as resources and integrated into our mental health practice is highly questionable.
Mental health professionals’ skills
Another barrier to physical health for clients is professionals’ skills. In a training needs analysis of inpatient and community mental health nurses’ physical care skills Nash (2005) found that
many of the sample did not have up to date physical care skills or knowledge. This may lead to a lack of confidence at taking on physical care activities or a lack of knowledge of symptoms of physical illness which might delay appropriate intervention. However, other past surveys reported that most psychiatrists did not examine their patients routinely and did not feel competent performing a physical examination (McIntyre and Romano 1977).
Box1.8 Exercise
SWOT Analysis
Think about your service/clinical area. What are the Strengths, Weaknesses, Opportunities and Threats regarding the physical health of clients? For example, a strength might be a routine physical assessment schedule; a weakness might be the ad hoc implementation of the physical assessment schedule
Conclusion
Being physically well is a goal for many people as good physical health can have a positive impact on psychological health. It is important that the physical health needs of clients are identified and effectively managed. Irrespective of the compulsion in the duty of care to clients, we should have a more vested interest in securing their good physical health. We cannot allow the glaring differences in morbidity and mortality between those with and without mental illness to continue.
Clients, like everyone, are concerned about their physical health, even though at times their lifestyle choices are at variance with this. This serves to illustrate the complex nature of beliefs and behaviours about physical health and illness. We should be hesitant in linking all lifestyle choices to the consequences of having a mental health problem and seek to address the physical health of clients in a truly holistic way. This will mean that we should assume less defeatist attitudes about clients not being able to change nor adopt a ‘you can’t teach old dogs new tricks’ philosophy.
If we really are in the business of holistic care we should be ensuring that physical health issues are addressed as part of the whole system approach to mental health care. This may require innovative practice and the use of what we already know in different ways. We can ensure physical health is integrated into local mental health documentation, e.g. the Care Programme Approach (CPA) in the UK, or advocating more loudly for our clients to have their physical health addressed in primary care settings.
This chapter should make us critically examine the notion that poor health in clients is solely lifestyle factor related. Undoubtedly lifestyle does play a part but all practitioners should continually reflect on their attitudes, approaches to physical care for clients, knowledge and skills and ensure that they have fair and equitable access to physical healthcare services.
Summary of key points
• Clients have poorer physical health and health outcomes than the general population due to inequalities of health and/or poor lifestyle choices.
• Clients are at greater risk of social exclusion which can negatively impact on health status.
• Mental health nurses need to develop a better understanding of clients’ health beliefs.
• Attitudes of healthcare professionals towards the physical health of clients may present as a barrier to care.
• Clients are concerned about their physical health status and practitioners should advocate for better physical healthcare services.
Quick quiz
1Define social exclusion. What effect will social inclusion have on the health status of clients?
2Describe the types of health inequalities that people with severe mental illness may face. How might these inequalities impact on physical health status?
3How might the negative attitudes of health care professionals affect the physical care of people with severe mental illness?
4What barriers to good physical health do clients face?
5What type of barriers to physical care can you identify for your client group?
An introduction to key concepts in measuring health and illness
By the end of this chapter you will be able to:
• Define key terms in health measurement, e.g. incidence, prevalence, standardized mortality ratio and mortality rate
• Illustrate how knowledge of epidemiology can help mental health nurses in practice
• Define demographics
• Discuss risk factors in respect to public health
• Describe the process for screening and profiling caseloads for physical illness
Introduction
List the factors that can increase your client’s risk of physical illness.
In Chapter 1 we discussed the effect of lifestyle factors, social class, health inequalities and adverse drug reactions on clients’ physical health. We should be mindful of these factors when profiling our population health as the WHO (2004a) suggest the clearest evidence is associated with indicators of poverty. This includes low levels of education, and in some studies, poor housing and poor income. Increasing and persisting socio-economic disadvantages for individuals and for communities are recognized risks to mental health.
This chapter will explore the epidemiology of physical illness in clients and will probably confirm what you already know from your clinical practice. However, it will strive to put this in the context of available evidence. We will explore the concept of risk, but in a different way from what is typical in mental health. We will consider risk factors for physical illness and how these can be examined and managed through the concept of health needs assessment.
Most of us will have considered the impact of client physical illness on our work. For example, how often do you now provide physical care compared to three years ago? What is the prevalence of diabetes in your client group or the incidence of problems associated with smoking? This is one way that we experience the influence of epidemiology on our work.
Coggon et al. (2003: 1) define epidemiology as ‘the study of how often diseases occur in different groups of people and why’. Therefore epidemiology can tell us
• which groups are more at risk of ill health
• what might cause certain groups to suffer more ill health than other groups
• which groups we should target with public health initiatives to reduce morbidity.
Epidemiology can also tell us about inequalities in health when we explore the health status of vulnerable groups such as our clients. This information may highlight areas of unmet needs which can then become the focus of interventions.
What epidemiology tells us in general is that physical health has become an increasing concern in mental health. The UK National Psychiatric Morbidity Survey showed high levels of physical ill health and higher rates of death among those with mental health problems compared to the rest of the population (DH 1999b). Indeed, such are the consequences of physical ill health in our clients that Allebeck (1989) suggests that schizophrenia itself is a life shortening disease.
Epidemiology has a significant impact on our practice in the guise of public health. We should all know the prevalence of mental illness in our society is 1:4 – one in four people has at least one mental, neurological or behavioural disorder but most of these disorders are neither diagnosed nor treated (WHO 2008a). Other statistics include the following:
• The prevalence of depression is estimated at 5–10 per cent of the population at any given time (WHO 2001).
• The prevalence of schizophrenia is between 0.5 per cent and 1 per cent (Murray 2005).
• The prevalence of bipolar disorder is approximately 1 per cent of the population (NICE 2006: 76).
What is public health?
Public health is the science and art of promoting health, preventing disease and prolonging life through the organized efforts of society (WHO 1998: 3). The ‘science’ is represented by both epidemiology, which can track patterns of health and illness, and evidence based practice, which is employed to promote health or reduce illness. The ‘art’ is mental health nursing; how our interventions can prevent mental illness and prolong life, e.g. suicide prevention and promoting positive mental health. A significant new challenge is incorporating physical health into our role in respect to preventing physical conditions and promoting physical well-being.
Box2.2 Exercise current client group.
How would you define incidence and prevalence? Illustrate this with reference to your
Defining some key public health concepts
Here we will explore key epidemiological concepts that can assist practitioners in implementing the physical health agenda in their settings. Whether it is inpatient acute care, long term rehabilitation or community mental health, a basic knowledge of these key concepts will enable you to focus on areas of greatest health need. This effective targeting of resources promotes evidence based practice enabling practitioners to effectively commission or advocate for physical health care services on behalf of their client group.
16
Demographics
Demographics is the study of human populations with regard to their current characteristics and short term trends. In general it is a particular aspect of the information collected every day and can relate to the following areas of health:
• Personal details: name, next of kin/nearest relative, address, date of birth, hospital number
• Social details: carer address/next of kin, GP address, other relevant contacts, e.g. social worker, probation officer, benefits status, housing status
• Medical history: past medical history, current medical history, current medication, adverse drug reactions
Box2.3 Exercise
Describe the demographic profile of your client group.
Health statistics
‘Illness’ and ‘health’ statistics are collected in many ways. Each of these acts as a barometer to the health of our clients and gives an idea of which groups, or problems, will require attention. Normally the most pertinent ones for practitioners refer to mental health care, for example, the prevalence of schizophrenia or the incidence of self harm in young people. However, what is becoming more apparent is the incidence and prevalence of physical illness in clients and more so, the high death rates for physical illness discussed in Chapter 1.
Health statistics are usually expressed as rates, that is, they indicate the frequency of something occurring. Rates can be expressed in a general way, referred to as crude rates, or they will be more specific, where they relate to specific groups within the population. For example, the rate of schizophrenia in the general population is 1:100. This means that for every 100 people, at least 1 will have schizophrenia. However, what is obvious about taking the rate is that it does not tell us how severe the schizophrenia is. Therefore rates only indicate frequency, not necessarily severity. Nevertheless, rates are important as they can give us information on how our services should be developed, or the training that practitioners may need, or the possible impact on carers. This part of the chapter will explore some useful types of statistics and illustrate how they can be used in our practice.
Figure 2.1 illustrates the prevalence of physical conditions in the general population and people with severe mental illness (SMI). It is clear that there are glaring differences in the frequency of conditions between the groups. The DRC (2006) also found that not only are people with SMI more likely to become ill, they are more likely to have poorer outcomes than those in the general population:
• People with learning disabilities or SMI die 5–10 years younger than the general population.
• Women with schizophrenia are 42 per cent more likely to get breast cancer.
• People with schizophrenia are nearly twice as likely to get bowel cancer (the second most common cause of cancer death in the UK).
• There is poor prognosis with physical illness: 22 per cent of people with CHD who have schizophrenia have died, compared with 8 per cent of people with no SMI.
The two most common rates that we have heard of are incidence rate (IR) and prevalence rate (PR). Remember the exercise at the start of the chapter? Compare your definitions of incidence and prevalence to those given below.
Figure 2.1 The prevalence of physical health conditions in people with schizophrenia and bipolar disorder
Source: Disability Rights Commission (DRC) (2006) reproduced with permission of the Commission for Equality and Human Rights
Note: These figures are similar to those found internationally.
Incidence
Incidence is a measure of the number of new cases of a condition in a defined population in a specified time. Incidence describes the frequency with which new cases of a condition are diagnosed.
Box2.4 Case example
Simon is a community mental health nurse who wants to examine the incidence of T2D in his current caseload. In January 2008 Simon found that four people on his caseload of 30 have a diagnosis of T2D. When the same group are screened six months later the total number of people with T2D is now eight. Simon already knows that there are four confirmed cases of T2D so only 26 were at risk of developing it. Therefore the incidence is 4/26 × 100 = 15 per cent. The incidence of T2D in Simon’s caseload is 15 per cent.
Prevalence
Prevalence is a measure of the number of all known cases of disease in a specific group. This can be calculated as a point prevalence – the number of known cases at a certain point of time; or as a period prevalence – the number of known cases in a certain period of time, e.g. one year. In general terms it is estimated that the prevalence of diabetes in people with schizophrenia can be 2 to 4 times higher than in the general population (Expert Consensus Group 2003).
Box2.5 Case example
The prevalence of T2D in Simon’s caseload is calculated as – all known cases of T2D (n = 8) divided by the total population at risk (n = 30); 8/30 × 100 per cent = 27 per cent. So the prevalence of T2D in Simon’s caseload is 27 per cent.
Mortality rate
The mortality rate (MR) can tell us a lot about the health of the general population and of specific groups within it. The MR will not only tell us the number of deaths, it can also tell us the number of deaths between groups, for example, men and women, social classes or of different causes of death. The MR that we most associate with mental illness is the suicide rate. However, with physical illness being so prevalent, we now know that deaths from physical conditions can be higher than those from suicide. Given the high rates of deaths from physical conditions we will need to ensure that we are tackling deaths from all causes and not just suicide.
We can be more specific about the MR by calculating the number of deaths in specific populations, e.g. the risk of mortality from coronary heart disease is increased in people with severe mental illness in the 18–75 years age group (Osborn et al. 2007). When looking at MR it is worth considering problems associated with, for example, cause of death. If there is an error in recording cause of death or cause of death is misdiagnosed then this will affect the quality of statistics through under-reporting. Sometimes for a cause of death to be established a postmortem may be needed and this may not often be done, apart from deaths in suspicious circumstances.
Standardized mortality ratio
The standardized mortality ratio (SMR) is the ratio of the actual number of deaths in a population to the number of deaths expected if the death rate was the same as the general population. The SMR uses 100 as a standard figure for the whole population. This signifies a national ‘average’ if all things were equal; it does not signify age. A figure over 100 is worse than the national average and a figure less than 100 is better. It is a good simple measure to compare areas of a country, groups within society or international comparisons at a point in time.
Let’s put the SMR into perspective for our clients. Research by Harris and Barraclough (1998) shows that people with SMI have higher SMRs than the UK general population in a range of conditions:
• Cardiovascular disease SMR 250
• Respiratory disease SMR 250
• Infectious disease SMR 500
This means that our clients will die 2.5 times more often from cardiovascular disease and respiratory disorders and five times more often from infections than the general population. Again the irony here is that in many cases, clients may be in contact with healthcare services, yet their physical health needs may not be adequately addressed. These SMR statistics emphasize why we should be focusing on the physical health of clients. With such disparate death rates practitioners should be prioritizing the assessment and screening of these types of conditions so that they can be detected early and prompt interventions given. 18
Life expectancy
Life expectancy (LE) is the average number of years a person will live before they die. In the UK the LE for men and women has continued to rise. At birth the LE for females born in the UK was 81 years, compared with 76 years for males (ONS 2004). However, if we look at the LE for our clients we can see that it is much worse than that of the general population. Farnam et al. (1999) state that people with SMI have a higher risk of preventable death, estimating that this group dies between 10 to 15 years earlier than the general population.
Morbidity rate
The morbidity rate is a measure of the frequency of an illness or condition in the population. Be careful not to confuse mortality and morbidity, as morbidity measures the rate of illness and not the rate of death. For example, there are high rates of medical co-morbidity in our client group, especially in schizophrenia. The Disability Rights Commission (2006) found that 31 per cent of people with schizophrenia and CHD are diagnosed under 55, compared with 18 per cent of others with CHD. The late detection of conditions such as heart disease and diabetes means that our clients not only have worse MRs than the general population, but the severity of morbidity is probably greater also.
Risk
Box2.6 Exercise which are non-modifiable?
List the risk factors for CHD in your client group? Which of these are modifiable and
In epidemiology risk relates to two things: the risk of developing an illness, or the risk that a particular intervention will work or not. As in mental health care there are many risk factors for certain conditions. A risk factor is something that can positively contribute to the risk event. For example, smoking (risk factor) can lead to lung cancer (risk event); poor diet (risk factor) can lead to a heart attack (risk event); or lack of exercise (risk factor) can lead to diabetes (risk event). From these three crude examples we can see the complex nature of relationships between risk factors and risk events. Will a lack of exercise alone lead to diabetes if the individual has a well balanced diet? What part does genetics play in this? We can also see that risk factors may not only be active (smoking) but also passive (not exercising).
Risk factors for physical illness
Risk factors can be dynamic or static; that is some are open to change, while some are not. Lifestyle factors are dynamic as with health education and promotion they can be modified, for example, smoking cessation therapy can reduce/eliminate smoking. Some risk factors are static; they are un-modifiable as health education or promotion cannot change them, for example, a genetic predisposition to an illness.
Risk factors for physical illness in our clients are the same as for the general population. It may be that the relationship between physical illness and mental illness presents us with an added level of complexity, but in general the risk factors are the same: sedentary lifestyle, poor diet, lack of exercise and smoking. A unique factor for our clients is psychotropic medication and the risk factors that this presents. This will be explored later in the book.
Exposure to risk factors
People with SMI have higher rates of physical illness than the general population which largely goes undetected (Brown et al. 1999). While many individuals are in contact with mental health or primary care services, the focus of interventions and interactions is naturally the primary psychiatric illness. If there is significant concern regarding physical health this will either be managed ‘in house’, or, depending on the severity or results from diagnostic testing, referred to either primary care services or acute/community hospital services.
When exploring illness we need to examine risk factors that can increase the risk of developing a physical condition. I am sure that you are aware of a range of risk factors that can lead to lung cancer. The most prominent one is smoking. However, there are some people who do not smoke that develop lung cancer. How can we explain this? One way is by examining their exposure to the risk factor. Therefore, while we might have an idea that people with mental illness smoke a lot, research indicates that the prevalence of smoking in people with SMI is significantly higher than that of the general population (McNeill 2001). If we explore this further we find that the rates of smoking are higher in individuals with psychotic disorders with some studies showing a prevalence of up to 80 per cent (McNeill 2001).
Our clients face increased exposure to a range of risk factors and physical illness. However, exposure to risk factors cuts two ways. While it is recognized that lifestyle factors account for some of the exposure to physical illness, the failure of health services to respond equally to clients’ physical complaints also exposes them to increased risk.
For example, in comparing the impact of different risk factors on the physical health of clients we find that:
• Lifestyle factors:
• Smoking rates are higher in individuals with psychotic disorders (McNeill 2001).
• 33 per cent of people with schizophrenia are obese compared to 21 per cent of the general population.
• Health organization factors:
• People with schizophrenia and stroke were less likely than the general population to have a cholesterol test.
• 63 per cent of eligible women with schizophrenia had a cervical smear compared to 73 per cent of women in the general population (DRC 2006).
While lifestyle factors may contribute to the cause of illness, failure to respond or intervene promptly, to modify lifestyle factors or identify illness early, might be the reasons that individuals go on to develop long term morbidity or early mortality.
Table 2.1 outlines risk factors for CHD. Social class has been categorized as non-modifiable for clients as social mobility for this group is hugely restricted due to stigma and social exclusion. The challenge for us is to replicate these categories of risk factors for the different conditions present in our clients.
What does this mean for our clients?
If these statistics are ignored then it means that the current dire picture of deaths and illness from treatable physical conditions will remain unchanged. Clients and carers will face the added burden of a co-morbid physical condition and a major mental health problem. However, if the nettle is grasped, these statistics challenge us to turn the tide of ill health in our client group. Now that we know the major areas of concern – obesity, diabetes, cardiovascular illness, respiratory illness and infections – we should really begin to integrate other national service
Table 2.1 Modifiable and non-modifiable risk factors for CHD
Non-modifiable risk factorsModifiable risk factors
GeneticsSmoking
AgeHypertension
GenderLack of exercise
EthnicityObesity
Family history of CHDAnxiety/stress
DiabetesAlcohol intake
Social classHigh cholesterol
Side effects of anti-psychotic medication
Mental illness diagnosis
frameworks such as that for CHD (DH 2000b) and the various NICE guidance into our work routine, at least at a level of screening and onward referral.
Putting these statistics to use
A common concern of practitioners is what do we do with these statistics; how do we put them to good use? The first point would be to ensure that the statistics are collected in the first instance. Without these there will be no way of knowing what the main health problems are or how to prioritize resources. Nevertheless we already have a general idea of the areas of concern but in order to effectively prioritize resources or commission services, we need to generate our own evidence regarding the prevalence of conditions. This is called health needs assessment.
Health needs assessment
As physical health is a neglected area in mental health care, it might be safe to say that we may not have a true picture of our clients’ physical care needs, unless they have a current condition. It is important that the physical health needs of clients are defined in partnership with the service user and not just left to professional opinion alone. Bradshaw’s (1972) definition of need is one of the best known ways of defining need and comprises four areas:
• Normative need: needs based on criteria as set by experts or officials, e.g. the number of beds needed for a population
• Felt need: the needs as wanted by the individual
• Expressed need: the needs that the individual expresses or demands themselves
• Comparative need: based on the needs when two groups are compared
Defining needs is complex as there will be tension between what policy makers, professionals and service users define as a need. It is disempowering for clients to have their needs diminished by diagnostic overshadowing (see Chapter 1) or to have them remain as unmet because mental health nurses or services are not up to the challenge of the physical health agenda. However, it should be recognized that needs might be identified but interventions not wanted, for example, clients that smoke may not want interventions such as smoking cessation. Health needs are relative to the individual and we may have a system of bargaining our health, e.g. being a social smoker – we know smoking is bad for us but we minimize the extent that we do it.
Box2.7
Physical health and well-being in mental health nursing
What are the most prevalent physical health problems in your client group? Would
Exercise your client group agree with you?
Caseload profiling
Twinn et al. (1996) define caseload profiling as the analysis of all individual records held by each community health care nurse. However, this is not to say that our ward based records do not need profiling at regular intervals. Profiling caseloads is important as it will help us to get an accurate picture of the physical health status of our clients. It will not only help us to estimate the prevalence of physical illness but also help us to identify unmet needs which need to be highlighted. Unmet needs are not only confined to client health but also include aspects such as areas to strengthen commissioning of physical health care, equipment for assessing and maintaining physical health and staff training needs.
Table 2.2 is an example of a caseload profile. This should be preformed against each of our client’s case notes. There may be obvious categorical differences in respect to what is measured. Local discussion and client or carer input will fine tune any tool.
Screening for physical conditions in clients
Caseload profiling requires us to have various clinical skills and theoretical knowledge, for example, therapeutic blood glucose levels, normal ranges for baseline observations. These procedures contribute to the process of screening which is defined as ‘the application of a special test for everyone at risk of a particular disease to detect whether the disease is present at an early stage’ (Ewles 2005: 283). Screening and assessment will be covered in more detail in the forthcoming chapters.
Potential benefits of health needs assessment
The benefits of health needs assessment speak for themselves: improved profiling can lead to more accurate prevalence statistics which can lead to more effective targeting of resources and interventions. Better statistics can also lead to better commissioning to underpin and support the physical health agenda. Clients can feel that their physical health is incorporated into a holistic nursing assessment. Advantages and disadvantages of health needs assessment are outlined in Table 2.3.
Box2.8 Case example
Staff nurse Ncube is increasingly concerned at the increasing weight gain in her client group. She brings this up at one of the staff meetings and it is agreed that, to help weight reduction, saccharine sweeteners will now be used on the ward rather than sugar.
As discussed previously, we need to have an idea of our clients’ health beliefs. This will enable us to more effectively collaborate on determining health needs. While we know that factors such as increased calorie intake and lack of exercise can increase weight, we cannot afford to be
The challenge for MHNs – meeting the physical health needs of clients
Cardiovascular healthNumber of people with cardiovascular problems
Severity of problems
Current treatment regimes
Substance misuseNumber of alcohol users
Degree of alcohol use by policy defined units
Prevalence of alcohol related disorders
Number of substance users
Degree of substance
Type of substance use
Mode of substance use
Prevalence of associated disorders HIV/AIDS, Hep C
Nutritional statusPrevalence of overweight/obesity
Degree of overweight/obesity as measured by BMI, waist-hip ratio, waist circumference
Prevalence of diabetes by type
Prevalence of metabolic syndrome
Pre-diabetes?
Current treatment for diabetes
Complications of diabetes
Social factorsBenefits
Social support
Housing
Debt/poverty/hardship
Leisure
Screening/preventionBreast screening
Cervical smear
Testicular screening
Immunizations/vaccinations
Sex education
Family planning
Healthy eating/dietary advice
Exercise
evangelical about interventions as clients may be put off by this. Individuals may know what the message is but may not yet be at the stage where they want to change and we cannot enforce change on clients. While staff nurse Ncube’s intentions may be honourable they seem very paternalistic as she is taking a well meaning decision on behalf of her clients. This diminishes their autonomy and ability to make decisions. This decision also limits the intervention to
Table 2.3 Possible advantages and disadvantages of health needs assessment
AdvantagesDisadvantages
Accurate local health needs to inform target settingServices and interventions rationed to specific areas
Better statistics for more appropriate commissioningNeeds classified as ‘unmet’ as few resources for commissioning available
Improved services/access to serviceNo extra resources means redistribution of mental health budgets which are already low
Improved physical health of clientsWhose responsibility is it for improving physical health – mental health services or primary care services?
Improved practitioner knowledge, skills and practicePractitioners may not see this as part of their role and may not be confident in extending their scope of practice
lifestyle and does not include either social factors that might impact on weight gain, nor associated adverse drug reactions. Therefore while the plan – to reduce weight gain – is positive the intervention – banning sugar and using sweeteners is ill thought through.
Conclusion
This chapter has outlined the importance of having knowledge of basic concepts in epidemiology. It also explored the real-life impact of these concepts on the physical health of clients thus laying down a challenge for practitioners to employ holistic assessments in our work. It introduced the concept of health needs assessment and illustrates how it may be used in practice. However, practitioners must be cautious with using epidemiological data in the planning and delivery of health services or health interventions. While this might be seen as effective targeting of resources by some, it may be interpreted by others as rationing health services or interventions. This principle of the greater good – doing something that benefits many – is a core principle of public health as policies are directed towards the biggest killers of the population, i.e. cancer, diabetes and CHD. But what if a client’s illness or condition is rare or difficult to measure epidemiologically? Finding oneself outside of the policies or interventions can be a frightening experience. Described as a post-code lottery – not being able to get treatment because your health authority/provider wants to focus on more substantial issues – means that we may need to undertake an advocacy role to ensure that clients’ physical health needs, or access to treatments, are not diminished.
Summary of key points
• Long term chronic and severe physical illness are more prevalent in clients than in the general population.
• It is important that practitioners have an understanding of key terms in epidemiology so that they can assess the health needs of their clients.
• While knowledge of key terms in epidemiology is important, the challenge is to do something effective with the statistics.
• Thorough health needs assessment can lead to more effective commissioning of physical health care services for clients.
• Practitioners need to develop skills in public health techniques such as screening, physical health education and health promotion.
Quick quiz
1In relation to your client group, list the health information that you collect.
2How do you think this information could be put to use?
3What are the local barriers you can identify to putting health information to use?
4How would you begin building a physical health profile of your client group?
5What is the prevalence of smoking in your current client caseload?
Clinical skills for physical assessment in mental health settings
By the end of this chapter you will have:
• Examined clinical governance and infection control
• Defined homeostasis
• Examined clinical observations such as temperature, pulse, blood pressure, ECG, pulse oximetry, respiration, collecting a sputum sample, peak flow, urinalysis, BMI, testing blood glucose, pathology tests for bloods
• Explored the relevance of observations in relation to mental health care
• Explored the process of care planning for some physical conditions
Box3.1 Exercise
Introduction
Which skills do you consider important for physical assessment?
This chapter will explore the clinical skills required for examining and monitoring clients’ physical health. Clinical skills are an important component of the nurse’s work and those discussed here are required either for direct observation, e.g. temperature, pulse and blood pressure, or for collecting various clinical samples for testing. Testing samples can be done on the ward, e.g. urinalysis, or sent to a pathology lab, e.g. a sputum sample.
The principles of infection control are important requirements when undertaking clinical observations. All local policies and procedures pertaining to the collection, handling and safe disposal of clinical waste should be followed conscientiously by practitioners. This is important in protecting the health and safety of both clients and staff.
When performing clinical observations or taking clinical samples, hand hygiene is very important. Practitioners should wash their hands and/or use alcohol hand rub before and after contact with clients. This will minimize the chances of cross infection while increasing client confidence and reassurance that infection control is taken seriously. Practitioners should also remember the practical aspects of physical assessment outlined in Chapter 2 when undertaking clinical observations.
Clinical governance
Clinical governance is defined as ‘an umbrella term for everything that helps to maintain and improve high standards of patient care’ (Currie et al. 2003: 7). There are a range of observations
used in physical assessment that we are trained to perform. However, there are risks involved in physical assessment and although small, they require management. Risks range from cross infection when using, or disposing of, clinical hazards to forgetting to perform, or document, a clinical observation. Clinical governance is the process of achieving high quality care through managing these risks.
Examples of clinical governance initiatives that manage risk and promote client safety include:
• Following established policies and procedures, e.g. infection control
• Developing and implementing clinical standards, e.g. physical assessment protocols
• Implementing clinical audit, e.g. auditing the effectiveness of physical assessment protocols
• Implementing evidence based practice, e.g. diabetes screening
• Clinical audit, e.g. evaluating the effectiveness of protocols
• Staff education and training, e.g. clinical skills refresher courses for all practitioners
• Accurate and consistent documentation and record keeping
It is important that organizations have an infrastructure in place to support physical health and well-being. This includes assessment protocols, equipment, resources and education and training. Investment in training and education is required as research by Nash (2005) shows that mental health nurses are highly motivated to undertake training in physical care skills.
This chapter will illustrate clinical observation skills within a mental health specific context. The framework for physical assessment is outlined in Figure 3.1. The first two steps have been covered in depth in previous chapters and are the first two steps in assessing the physical health of clients. The general survey will tell us general information; the physical assessment will support our general survey findings; and the clinical observations will corroborate our findings and confirm whether or not further investigations are warranted.
While there are a wide range of clinical observations those that will be covered in this chapter include:
• Temperature
• Pulse
• Blood pressure
• Electrocardiogram
• Pulse oximetry
• Respiration rate
• Collecting a sputum sample
• Peak flow
• Urinalysis
• Body mass index
• Testing blood glucose
• Pathology tests for bloods
The rationale for selecting these is that they are the key observations associated with the prevalent physical illnesses outlined in this book. Other clinical skills are undertaken by more appropriately qualified nurses, e.g. a diabetic leg ulcer assessment will be undertaken by a tissue viability nurse or diabetes nurse specialist. However, skills can be taught and it is important that
Define homeostasis.
Box3.2 Exercise
Figure 3.1 The process of physical assessment and observation
our repertoire of skills in physical care grows. This can be reflected in our post-registration education where we may opt for courses in physical health such as tissue viability.
The key techniques in physical assessment are
• observation
• palpation
• inspection
• auscultation
Rationale for taking baseline observations
Baseline observations are an essential part of the physical assessment of an existing condition or the monitoring of an established one. These observations provide clinically important data such as
• baseline measurements for future comparison
• screening for previously undiagnosed conditions
• monitoring previously diagnosed illnesses
• determining the response to treatment of a current physical illness
• monitoring the course of a current physical condition(s)
• promoting early intervention
• selecting the best intervention or treatment
When undertaking clinical observations you should endeavour to protect the client’s privacy and dignity.
