“It’s not my job.” “That’s not in my scope.”
Mental health and physical health have long been the scope of all comprehensively trained nurses, but over time, nurses tend to “stick to their knitting”.
So a community mental health nurse’s stethoscope and blood pressure cuff may be gathering dust in the glove box, a practice nurse may be uncomfortable in offering smoking cessation support to a person with schizophrenia, or an emergency nurse may risk dismissing a physical health symptom as a mental health symptom.
A study led by Ruth Cunningham of the University of Otago* and published recently in the New Zealand Medical Journal highlighted has been long known – long-term mental health service clients have poorer physical health and die prematurely.
But Cunningham’s study quantified for the first time how big the problem is in New Zealand, with the death rate of people with psychotic disorder diagnoses, such as schizophrenia, before the age of 65 being three times that of the total population – most of those being from natural deaths, particularly cardiovascular disease and cancer.
Her study joins the growing call to make improving the physical health of people with mental illness everybody’s “knitting”.
Heather Casey, director of nursing for Southern District Health Board, points out that the New Zealand Health Strategy back in 2000 highlighted the need to “improve the health status of people with severe mental illness”, and in 2004, the Mental Health Commission published Our Physical Health… Who Cares to try and provoke debate and action on that very issue.
Marion Blake, chief executive of the Platform network of non-government providers of mental health and addiction service, acknowledges the issue is not new with the evidence long available.
The momentum for the trust built a few years ago as providers around the Platform board table started increasingly reporting “we’re seeing so many of our clients dying”, recalls Blake.
The issue of poor physical health was seen to be a whole-of-system issue, and in 2013, Platform joined forces with mental health and addiction workforce development agency Te Pou to gather New Zealand-based evidence about the issue and practical solutions.
The result has been the Equally Well evidence review which, in addition to Cunningham’s research, has confirmed that Kiwis with an ongoing mental illness or addiction not only have significantly higher physical health problems related to metabolic syndrome (the taking of anti-psychotic medications can lead to an average weight gain of 12 kgs in the first two years) but also viral and oral health diseases, respiratory diseases, cancers, diabetes, and cardiovascular diseases.
The research also found that, like elsewhere in the world, there is not one single factor leading to the poorer physical health of mental health clients but many.
The picture is not a rosy one. Often mental health clients have fallen out of the routine population health screening (or have been put into the ‘too hard basket’); until recently smoking and second-hand smoke was a commonplace and accepted lifestyle risk (mental health clients’ smoking rate is three times the average Kiwi rate); and added to the mix is medication side-effects, poverty, discrimination, and stigma, along with system and workforce issues. The result is a perfect storm for poor health outcomes.
Anne Brebner, nursing clinical advisor for Te Pou (and the newly elected president of the College of Mental Health Nurses), says, apart from drawing attention to the issue through Equally Well, the area Te Pou can help most in is supporting the training of the workforce.
The nursing area she sees needing the most support is not practice or other primary health nurses – though work is being done to upskill them in mental health – but the dedicated mental health and addiction nursing workforce itself.
“Historically, mental health and addiction nurses have just done the one thing really well,” says Brebner.
Despite the vast majority having been comprehensively trained, the pressures of high caseloads meant many retreated to their ‘core business’ of mental health and physical health monitoring often fell by the wayside.
But Brebner says there is now recognition that mental health nurses needed to ‘widen the lens’ and pay greater attention to clients’ physical health needs, with physical health workstreams at recent mental health nursing conferences showing nurses are keen to improve their skills in this area.
“It doesn’t take much to reignite or reinspire comprehensive nurses with the knowledge base they already hold,” says Brebner.
Daryle Deering, outgoing president of the College of Mental Health Nurses, says another issue in the past has been confusion about whose role the monitoring of physical health is: primary care or mental health services?
The College has recently stepped in to offer a credentialing programme in mental health for primary health care nurses which has highlighted that, while this generation of nurses may have been comprehensively trained, if they end up working primarily in physical health or mental health, their skills can lapse in either health dimension.
Deering says there has been a “huge push” to integrate or fuse the two back together and the College’s revised standards for practice for mental health nursing explicitly states that mental heath nurses are expected to address clients’ physical health needs either directly or by referring, consulting, and co-coordinating their care. Likewise, a primary health care nurse needs to be proactive to follow-up missed appointments by mental health clients and have close relationships with their community’s mental health nurses.
With the call from the government for greater integration between health services, Deering says the time is ripe for things to change. “You could argue that it’s a national disgrace.”
She also argues that people with mental illness are not alone, with many of the same factors leading to people intellectual disabilities having compromised health.
A common concern raised with Nursing Review was that somewhere along the way the mind and body or physical and mental health had been divided and siloed at the expense of the holistic care of patients. New Zealand’s comprehensive and broad scope of nursing was narrower as a result.
Blake believes everybody working with mental health clients–from community support workers, mental health nurses and psychiatrists through to GPs, practice nurses, and hospital health professionals–have to develop their responses to addressing and improving the physical health of long-term mental health patients.
“It’s almost like connecting the head back to the body,” says Blake. “Some of the practices we have are putting people at higher risk.”
More could be done to help mitigate, rather than accept, the weight gain side effect of some medications, with early onset diagnosis meaning some young people can start such drugs at 17 or 18. If uncontrolled, the weight gain can impact on their mental health and head them down the path to metabolic syndrome and Type 2 diabetes.
“We have all stepped back and said ‘this is not my job, I can’t deal with this’ … but we need to step up,” says Blake.
She was particularly taken by the higher cancer death rate of people with mental illness.
“There’s no reason why that population group should have a higher rate than anyone else in the population. What is that about? Is it we’re not screening people and not doing any intervention that we would do for the rest of the population? I don’t know whats the answer is but [Cunningham’s findings] really do raise questions.”
Equally Well hopes to highlight the questions and provoke a concerted effort to come up with some solutions to the factors behind the poor physical health of our chronically mentally ill.
The next step is formulating a consensus statement backed by key stakeholders, acknowledging poor physical health is a key problem for the mentally ill and a problem that can’t be ignored.
The goal is that fewer people will say “that’s not my job” and more will ensure it is part of their ‘knitting’ in the future.
Yes, it is in your scope
A leader in getting the blood pressure cuff out of the glovebox and into the mental health nurses’ usual ‘toolkit’ has been Southern District Health Board.
Heather Casey, the DHB’s director of mental health nursing, says back in 2006 it became clear to her that not all her staff saw the physical health of their clients as their shared responsibility. “Some nurses used to say ‘this isn’t in my scope’.”
Casey says mental health nurses have a very broad scope of practice, including physical health, which is also the point of difference between nurses and some of the other disciplines working in mental health.
“Mental health nurses need to have adequate skills and knowledge to respond to the physical health needs of the people we work with.”
Rather than wagging fingers or telling nurses what to do, she put in place a three-year plan aimed at raising awareness of the poor physical health of mental health consumers and supporting acute and community mental health nurses to develop their physical health knowledge and skills.
“A lot of times, [knowledge and skills] have been lost over the years – so we weren’t blaming nurses for not having those skills.”
Something had to be done.
“People are dying; people we have worked with for years are dying a lot earlier with respiratory illnesses, cancers, cardiac problems…
“It’s not necessarily that [mental health] nurses need to do the full assessment, but they need to know the risks and what to monitor or refer on to their GP,” says Casey.
They also need to be aware that a mental health nurse may be the only person working with a client and can be the best person to provide oversight of their physical health needs. This includes supporting and encouraging someone – who otherwise might fall through the cracks – to have a cervical smear, see their general practice about weight gain, or to ask for a prostate check.
The first year of the plan included monthly forums on topics ranging from vital signs to routine cancer screening, diabetes to wound care, and interpreting lab tests to health promotion. The second year, the DHB brought in documentation and guidelines for consistent metabolic monitoring of consumers on antipsychotic medication. Nurses were encouraged to educate consumers on healthy lifestyle choices, and pamphlets on medication, weight gain, and lifestyle choices were produced. The third year brought more physical health workshops with a focus on ‘hands-on’ learning.
Casey says a focus of late has been on staff being able to get their hands on the right equipment for physical health.
“Often in mental health, the physical health monitoring equipment has been appalling over the years. So making sure people had good functional equipment was really important.”
While there was usually a blood pressure cuff and stethoscope in the glove box of nurses’ cars, they weren’t always functional, says Casey.
“We’re following up an overarching policy document that pulls all of that together and lays out what the [physical health] expectations of the service are.”
This includes an expectation that all mental health nurses will go through the physical health workshops, which are held monthly.
Having taken an approach of focusing on, first, awareness then developing mental health nurses’ competence and confidence in physical health, Casey says they have had very little resistance.
Up the hill, down the hill, and meeting in the middle
Nurse educators from up the hill at Auckland City Hospital’s main hospital are working down the hill beside their acute mental health nursing colleagues in an initiative to boost physical health skills.
Nurse educators Tessa Grant and Alicia Sutton say the learning is definitely a two-way street, with them also taking their new mental health skills and awareness back up to the main Auckland City Hospital.
Sutton was the first to work at Te Whetu Tawera, the 58-bed acute mental health unit down the hill from Auckland City Hospital, when she was seconded four years ago from vascular services to be a medical-clinical coach for nurses with tuned mental health skills but often under-utilised physical health skills.
Conscious of the need to improve mental health service users’ physical health, the aim was to boost the confidence and knowledge of mental health nurses in assessing and responding to general health issues – including metabolic syndrome – while mental health clients were in acute care.
“Initially, I felt like a fish out of water,” recalls Sutton.
While a number of nurses were keen from the start to brush up and build their physical health skills, some others surprised her by saying “it’s not my job”.
“They said physical health concerns belong in the main hospital.”
Sutton says a key to changing the culture was rolling up her sleeves and working alongside staff to “teach rather than do”. That included getting back to the basics of refreshing people on taking blood pressures, how to assess patients who became physically unwell, and initial responses to medical emergencies. It meant ensuring that the nurses not only had the skills to do a regular set of ‘obs’ but also the confidence to act on the results.
“It’s all there, and it comes back really quickly for a lot of them,” says Grant of the largely comprehensively trained mental health nursing team.
Grant says by the time she stepped in to take over the role two years later – now called an adult medicine nurse educator – it was like a well-oiled machine. Most nurses had taken on board what they had been taught and a policy of routine observations had been implemented, but the new challenge was maintaining and embedding those tasks and knowledge into the mental health nurses’ already busy working day.
“One of the hurdles has been implementing care plans such as fall care plans and pressure injury care plans. This is all additional paperwork.”
The pair says key gains from the educator role included the acute mental health nursing team having the skills and knowledge to pick up patient deterioration a lot earlier and intervening to treat it on the ward or transferring them to the main hospital when needed. Grant says acute mental health admissions can quite often be due to an underlying physical illness, leading to a deterioration in their mental wellness. The increased monitoring and assessment skills has helped the team know which illness should be the initial focus.
“[The role] has also improved the communication between ‘up the hill’ and the mental health unit,” says Sutton.
The acute mental health unit and community nurses have the opportunity to go to the main hospital for adult health study days, where they can learn about diabetes to cardiovascular disease alongside nurses with a medical and surgical background.
While continuing her educator role at Te Whetu Tawera, Grant is also working with the small nursing staff at the district health board’s rehabilitation residential unit. She says she is very keen to work as holistically as possible with their clients. The next step is to start working with the community teams, in ‘bite-size’ groups, to help them focus on reducing the risk and impact of diabetes and cardiovascular disease amongst mental health service clients.
Meanwhile, the pair say they continue to be a link between services and when they return to the main hospital they bring with them an increased respect and understanding of mental health nursing skills and how hard both services work.
Premature death in Kiwi mental health service users:
- Looked at the 266,093 people who between the ages of 18–64 had contact with mental health services between 2002 and 2010.
- Excluded people with dementia, intellectual disability, or who had first contacted services three months prior to their death.
- It found that both men and women using mental health services had twice the risk of the total population of dying before age 65 with an increased risk of death from cancer and cardiovascular disease.
- The premature death rate was even higher for those with a psychotic disorder (three times the total population) with the risk of metabolic syndrome from antipsychotic medication a likely cause, along with socioeconomic deprivation and discrimination.
- The majority of the deaths were due to natural causes (71% for women and 58% for men) with suicide accounting for 15% of premature deaths in women and 22% in men.
- Premature mortality in adults using
- New Zealand psychiatric services, by Ruth Cunningham, Debbie Peterson et al; published in New Zealand Medical Journal 23 May 2014.