ArticlePDF AvailableLiterature Review

Challenges in acute care of people with co-morbid mental illness

July 2014
British Journal of Nursing 23(13):728-32

DOI:10.12968/bjon.2014.23.13.728

Source
PubMed

Authors:

Jo-Ann Giandinoto

Australian Catholic University

Karen-Leigh Edward

Swinburne University of Technology

Acute secondary care settings are complex environments that offer a range of challenges for healthcare staff. These challenges can be exacerbated when patients present with a co-morbid mental illness. This article is a systematic review of the literature that has investigated the challenges imposed on health professionals working in acute secondary care settings where they care for patients who experience co-morbid physical and mental illnesses. A systematic search of the bibliographic databases was conducted and a total of 25 articles were included in this review. A number of challenges were identified including experience of fear, negative attitudes, poor mental health literacy, being positive and optimistic in providing care as a profession and environmental factors. Health professionals working in acute secondary care settings require organisational support and training in mental health care. Acute secondary care environments conducive to providing holistic care to patients experiencing mental illness co-morbidity are required.

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728 British Journal of Nursing, 2014, Vol 23, No 13

Challenges in acute care of people

with co-morbid mental illness

Abstract

Acute secondary care settings are complex environments that offer

a range of challenges for healthcare staff. These challenges can

be exacerbated when patients present with a co-morbid mental

illness. This article is a systematic review of the literature that has

investigated the challenges imposed on health professionals working

in acute secondary care settings where they care for patients who

experience co-morbid physical and mental illnesses. A systematic

search of the bibliographic databases was conducted and a total of

25 articles were included in this review. A number of challenges were

identified including experience of fear, negative attitudes, poor mental

health literacy, being positive and optimistic in providing care as a

profession and environmental factors. Health professionals working

in acute secondary care settings require organisational support and

training in mental health care. Acute secondary care environments

conducive to providing holistic care to patients experiencing mental

illness co-morbidity are required.

Key words: Mental illness ■ Physical illness ■ Co-morbidity ■ Health

professional ■ Nurse ■ Experience

People living with a mental illness are more likely

to have a physical illness when compared to people

without a diagnosis of mental illness (van der Kluit

and Goossens, 2011; Edward et al, 2012; Scott et al,

2012). People with serious mental illness such as schizophrenia

have a mortality rate of up to four times that of the general

population and it is estimated that they have a reduction in

lifespan of between 10 and 30 years (Bressington et al, 2014).

Those who have an experience of mental illness often have

difficulty in seeking and accessing appropriate and timely

physical health care (Hahm et al, 2008; Thornicroft, 2008).

Improving the health care of people experiencing mental

illness is a healthcare priority worldwide—in the UK, the

Department of Health has developed initiatives and directives

to improve the integration of physical and mental health care at

all levels (Social Care Local Government and Care Partnership

Directorate, 2014).

Jo-Ann Giandinoto and Karen-leigh Edward

Acute secondary care settings, such as the emergency

department, general medical ward, medical-surgical ward,

and intensive care unit are complex, busy, task-oriented

environments that in themselves have well-known challenges

for healthcare staff in providing optimal care to all patients;

these challenges are often exacerbated when patients present

with a co-morbid mental illness (Sharrock and Happell,

2006). The challenges faced by health professionals in the

management of the physical health care of people who

experience a mental health co-morbidity include factors

such as stigma and discrimination, fear of aggression potential,

suboptimal mental health literacy in generalist healthcare

staff and the lack of adequate time and resources to meet the

needs of people who experience mental illness (van der Kluit

et al, 2013).

The tolerated use of derogatory and pejorative terms

to refer to people experiencing mental illness in acute

secondary care settings by health professionals strengthens

the effects of stigma and the potential for discriminatory care

(Sartorius, 2007). The general public may perceive people

who experience mental illness as:

‘Strange, frightening, unpredictable, aggressive

and lacking self-control ... and are associated

with negative stereotypes such as being violent

and dangerous’ (Björkman et al, 2008).

These stigmatising notions can also be found in health

professionals (Horsfall et al, 2010). Romem et al (2008)

further suggest that unlike people with a ‘physical’ health

condition people who experience mental illness, throughout

history, have been subject to discrimination and prejudice

perpetuating the development of pessimistic and apprehensive

attitudes.

The challenges associated with caring for patients who

experience a mental illness in acute secondary care settings are

often associated with the notion that health professionals are

not immune to the effects of stigma despite formal education

in psychiatry (Thornicroft, 2008). The complexity of such a

patient who experiences a serious mental illness on an acute

ward can lead to him or her being labelled as ‘difficult’ by

health professionals and consequently treated with caution

or avoided (Zolnierek, 2009). Patients who are identified as

difficult are often perceived by healthcare staff to take up

more of their time, as a disruption to their daily routine, as

taking time away from the care of their other patients, or are

avoided; all of which impact on the development of effective

therapeutic alliances. The challenges of caring for a patient

in the acute secondary care setting can be quite apparent

Jo-Ann Giandinoto, Research Assistant, Karen-leigh Edward, Associate

Professor of Nursing Research, Faculty of Health Sciences, Australian

Catholic University and St Vincent’s Private Hospital, Melbourne.

Accepted for publication: June 2014

SYSTEMATIC REVIEW

British Journal of Nursing, 2014, Vol 23, No 13 729

for the patient who experiences symptoms of mental illness,

including suicidal and self-harming behaviours, aggression

and confusion. This patient can display unusual behaviours

evoking a sense of caution in health professionals due to the

real or perceived threat of their own safety, or may be out of

their scope of practice, expertise or knowledge.

This systematic review aimed to examine the available

literature related to the challenges health professionals

experience while working in acute secondary care settings

and caring for patients with co-morbid physical and mental

illnesses. The benefits of such examination of the literature

are to provide further insight and understanding about the

challenges of caring for patients with co-morbid mental and

physical illness who are admitted to acute secondary care

settings and contribute to potentially raising awareness for

the potential for stigma and discriminatory care practices and

recommend means to mitigate such challenges.

Method

The bibliographic databases of CINAHL, Academic Search

Complete, MEDLINE, PsycINFO and ProQuest were

searched between May and June 2013. The search was

conducted by entering the keywords in Box 1 into each of

the databases.

The electronic search was based on the following inclusion

criteria:

■Peer-reviewed journal articles

■Published between 1985 and 2013

■Articles addressing the challenges of health professionals

caring for people with co-morbid physical and mental

illness while working in acute secondary care settings

(e.g. medical-surgical wards, emergency departments and

intensive care units).

Articles that were excluded from the search were those that

addressed challenges of mental health professionals working

in psychiatric settings and challenges related to primary care

and community-based health settings.

The above search strategy yielded a total of 2992 articles

due to the use of a large number of keyword combinations

and the broad subject nature of the keywords. The title and

abstract of each article were reviewed to ensure the articles

matched the above inclusion criteria and once duplicates

were removed 43 articles were returned. The final inclusion

of the article was based on extensive reading and further

assessment of the criteria and subsequently 25 articles were

identified for this review. An overview of the selection

procedure is depicted in Figure 1.

The quality of the research was assessed with reference to

the Critical Appraisal Skills Programme (CASP) qualitative

research checklist and the CASP cohort studies methodological

checklist (Taylor et al, 2000). Data were extracted by the two

researchers. Extracted data were collated and synthesised.

Results

Twenty-five articles were included in this review. Of those

identified, 12 were quantitative and 13 articles were qualitative

in design. All studies were included based on relevance to the

research focus and were not excluded based on methods or

instruments used.

Exclusion

on title and

abstract

6 duplicates

Article read

for relevance

to research

questions

2992 hits

abstracts

25 articles

964 CINAHL

589 Academic Search Complete

485 MEDLINE

729 PsycINFO

225 ProQuest

Figure 1. Flowchart of returned and selected articles for review

Box 1. Search terms

■ Mental illness* OR mental health OR psychiatric illness* or

disorder

■ AND physical OR somatic OR somatoform OR chronic

health OR illness OR disabilit*

■ AND general hospital* OR acute medical setting* OR ward*

OR medical surgical

■ AND health or medical personnel OR health professional*

OR nurse* OR physician* OR dietician* OR social worker*

OR psychologist* OR physiotherapist* OR occupational

therapist* OR pharmacist* OR multidisciplinary team

■ AND treatment* OR health care OR attitude* OR

experience* OR perception*

Discussion

The review revealed a number of themes, including: the

experience of fear, negative attitudes, poor mental health

literacy, positivity and optimism of care as a profession, and

environmental factors impacting care.

The experience of fear

Some studies reveal that fear prevents health professionals from

effectively caring for people who experience mental illness in

the acute secondary care setting (Atkin et al, 2005; Arnold and

Mitchell, 2008). The findings included expressed concerns of

fear towards patients with a mental illness due to a perception

of unpredictability and dangerousness causing healthcare staff

to be hyper-vigilant and concerned for their own safety and

that of their other patients (Mavundla et al, 1999; Lethoba

et al, 2006; Adewuya and Oguntade, 2007). Brinn (2000)

also discusses negative emotions expressed by nurses who

cared for those with co-morbid mental illness, such as fear

and wariness owing to an expectation of aggression. Other

730 British Journal of Nursing, 2014, Vol 23, No 13

research points to negative and discriminatory care because

of a psychiatric diagnosis where patients are thought to be

unstable and difficult and this is exacerbated when the care

setting lacks protocols or support to effectively manage such

patients (Chow et al, 2007). Nurses in one study felt despair

and frustration, which affected their social and psychological

functioning (Mavundla et al, 1999). Another study used a

randomised controlled trial to assign health professionals to

different case-study groups; participants were exposed to a

case study that depicted negative images of dual diagnosis

such as forensic history and dual diagnosis and more positive

images such as patients in recovery/remission (Rao et al,

2009). These researchers revealed that patients with a dual

diagnosis (i.e. diagnosis of mental illness and substance

misuse disorder) and forensic history elicited the most stigma

and apprehension when compared with a mental illness

co-morbid with a physical illness diagnosis alone.

Negative attitudes from staff

and a label of mental illness

The major findings of the studies were that health professionals

had a number of challenges related to caring for patients

experiencing mental illness in acute secondary care settings

relating to the label of a mental illness and the stigma associated

with such a label (Arnold and Mitchell, 2008). Patients, too,

are often identified by the unusual behaviours they display

(Atkin et al, 2005) and such patients were considered to be

demanding and difficult to talk to (Björkman et al, 2008).

Stigma negatively affects the relationship between the patient

and the health professional, where it can lead to avoidance

through fear of not wanting to offend and on the other

hand patients can often self-stigmatise (Liggins and Hatcher,

2005; Zolnierek and Clinger man, 2012). Negative attitudes

can stem from a lack of positive reinforcement for caring for

patients experiencing mental illness and especially on wards

such as the intensive care unit a paradox exists between caring

for a patient and the patient wishing to die (i.e. suicidal

patients) (Bailey, 1994; 1998). MacNeela et al (2012) found

that most nurses adopted a ‘risk attitude’ when looking after

patients experiencing mental illness. They explained that the

stereotyped perceptions of patients experiencing a mental

illness, such as non-compliance, absconding and a violence

risk, altered their experience and expectations of care and

moreover this justified the need for chemical/physical

restraining of patients.

The review exposed a number of factors that can positively

decrease the challenges faced by health professionals: increased

exposure and direct contact with patients who experience a

mental illness, increased age of the health professional, level

of education and professional experience and increased

familiarity with mental illness (having a personal lived

experience such as family member or friend with mental

illness) (Arvaniti et al, 2009). Clinical education as professional

development and support in the way of mental health liaison

produced more positive attitudes from staff towards patients

with mental illness co-morbidity (Priami et al, 1998).

However, familiarity or having a personal experience of

mental illness did not always predict a positive attitude from

health professionals (Aydin et al, 2003).

Poor mental health literacy

The frustrations reported by hospital staff related to caring

for patients experiencing mental illness seemed to stem

from knowledge gaps or skill deficits and mostly related to

ineffective therapeutic interaction and subsequent feelings

of inadequacy and professional dissatisfaction (Arnold and

Mitchell, 2008). Some health professionals, despite having

medical knowledge, held stereotyped views about the origins

of mental illness parallel to those found in the general

public (e.g. spiritual causes), and unfortunately some health

professionals maintained blaming attitudes towards people

experiencing mental health problems thus creating real

barriers to providing care and aiding recovery of mental

illness (Adewuya and Oguntade, 2007; Fernando et al, 2010).

The review exposed that most generalist nurses identified

that assessment and management of patients experiencing

a mental illness was outside their scope of practice or not

part of generalist nurse competencies. Many nurses felt

that their undergraduate training was not adequate and felt

they required training on an ongoing basis in mental health

literacy (i.e. diagnosis, psychopharmacology, management,

legislation).

Nurses also reported that they lacked the requisite skills

to effectively engage in therapeutic communication with

patients who experience a mental illness (Bailey, 1998).

There was a perception that caring for complex patients

required a specialist set of skills. Feelings of inadequacy and

role conflict meant many described feeling professional

distress, disempowerment, low levels of satisfaction and

burnout when caring for patients with a co-morbid mental

illness (Harr ison and Zohhadi, 2005; Plant and White, 2013).

Harrison (2007) suggests that role conflict may be attributed

to dualistic thinking where not only is there a metaphorical

divide between mind and body but a literal divide where

physical and mental health care were not traditionally

integrated. Nurses lacking in knowledge and capabilities to

effectively assess and manage mental illness in acute settings

has been recently noted in a qualitative study exploring

nurses’ experience in the care of patients with delirium (Agar

et al, 2012). Nurses reported a superficial understanding

of the condition where it was often under-recognised and

poorly managed in the acute setting leading to detrimental

outcomes for patients and their families.

The returned evidence suggests that while education may

be beneficial for improving perceptions and attitudes of acute

medical staff towards patients with co-morbid mental illness,

the effects are short lived and the positive effects reduce

over time (Aydin et al, 2003). Education may be a way of

increasing self-awareness and reflection and it is by these

strategies that a reduction in a tendency for stigmatising

attitudes to prevail may occur (Mavundla and Uys, 1997;

Solar, 2002). Addressing stigmatising attitudes held by health

professionals may not be as simple as increasing exposure

or education. Further research is required to determine the

origins of such attitudes, and as such qualitative research

designs may be used to investigate whether stigma is

enabled by actual negative experiences or is a reflection of

predisposed prejudices (Björkman et al, 2008) or cultural

influences and values (Fernando et al, 2010).

SYSTEMATIC REVIEW

British Journal of Nursing, 2014, Vol 23, No 13 731

Being positive and optimistic in care

considerations as a profession

The review included research from a qualitative paradigm

and the main findings of these studies incorporated detailed

descriptions of the challenges health professionals find in

caring for patients with multiple and complex needs when

they experience co-morbid physical and mental illness. In

contrast, some of these studies highlighted positive and

optimistic attitudes from some nurses working on the

general medical wards towards patients with mental health

problems. These nurses described striving to provide care in

an ethical and conscientious manner, but acknowledged that

they lacked the knowledge and training to do so adequately

(Reed and Fitzgerald, 2005; Sharrock and Happell, 2006).

Sharrock and Happell (2006) reveal that while nurses

were endeavouring to fulfil their duty of care in providing

patients with their required care, these nurses felt ill-

equipped and there was a real void between the theory of

providing holistic care, including psychological care, and the

reality of task-based nursing practice on general medical

wards. Similarly, Reed and Fitzgerald (2005) found negative

attitudes and feelings among nurses such as fear, dislike,

‘not my role’, lack of time and support and feeling patients

with this co-morbidity did not belong on the wards and

balancing this with a strong desire to ‘do the right thing’ by

their patients but lacking resources, skills and knowledge to

do so. Unsurprisingly, positive experiences lead to positive

attitudes and negative experiences lead to negative attitudes

(Mavundla and Uys, 1997; Reed and Fitzgerald, 2005).

Some health professionals wanted to provide holistic care

and experienced a dilemma in not being able to cater for

all the patients’ health needs owing to their limitations in

knowledge and restrictions in their clinical environment

with regards to support and resources required in order to

provide individualised care.

Environmental factors impacting care

The physical environment offers a number of challenges

in the general ward context of a hospital when caring

for patients who have co-morbid mental illness. Patients

experiencing mental disorders often require a therapeutic

milieu to aid recovery, and when patients are considered

as not fitting into the purpose of the environment, health

professionals’ attitudes can alter, frustrations increase and

fears become apparent with stigmatising and stereotyping

behaviours presenting (Zolnierek and Clingerman, 2012).

This approach to care is often sensed by the patient and can

result in further adverse clinical outcomes. The environment

in which general medical health professionals work is often

complex, busy, sterile, has a lack of privacy (often just a

curtain to screen the patient) and can be noisy when patients

might require a quiet space. Hopkins (2002) found that

patients experiencing a mental illness were perceived as

presenting an additional challenge to the impending routines

and functions of a ‘busy’ acute medical setting, the lack of

time and resources in these complex settings lead patients to

be considered difficult and thus they received depersonalised

care. Supportive and informative work environments that

recognise the complexity of these patients are also required to

assist health professionals to provide holistic care (Shafiei et al,

2011; Goldberg et al, 2012; Plant and White, 2013).

Limitations of the review

The limitations of this review relate to the diverse types of

the research returned making any generalisations prohibitive.

Another limitation was that only peer-reviewed literature

written in English was included, potentially omitting eligible

evidence.

Conclusions and implications

The management of the physical health care of people who

have a mental health co-morbidity presents several challenges

for healthcare staff. The challenges associated with caring for

patients who experience a mental illness in acute secondary

care settings in particular are often linked with the notion

that health professionals are not immune to the effects of

stigma attached to mental illness, despite formal education

in psychiatry. Health professionals reported experiencing fear

of the patients in their care and holding negative attitudes

towards those with a diagnosis of mental illness. These

experiences for staff are often hampered by environments

that are not conductive to engaging with patients in the

development of a therapeutic alliance.

Health professionals, in some instances, reported a positive

attitude and strived to care for people experiencing mental

illness. However they also acknowledged their inadequacies

to care for them holistically because of factors including poor

mental health literacy and low level of confidence to intervene

in challenging clinical occasions. Mental health competencies

and undergraduate training may not satisfactorily prepare

nurses to care for patients with this co-morbidity in non-

psychiatric settings. This review highlights a recommendation

to hospitals to provide professional development opportunities

and additional support by way of mental health education and

compulsory training modules facilitated by mental health

professionals for the generalist nurse. In addition to training

KEY POINTS

n

Acute secondary care settings are complex, busy, task-orientated

environments that present a range of challenges to providing optimal care to

patients; these are often exacerbated when patients present with a co-morbid

mental illness

n

Health professionals, despite formal training in mental illness, are not

immune to negative attitudes and stigmatisation of mental illness

n

Professionals in acute secondary care settings describe the experience of

caring for patients with a co-morbid mental illness as challenging due to

feelings of fear, of not knowing and of feeling unsupported

n

The routines and physical aspects of the acute secondary care environments

are not conducive to optimal care for a patient experiencing mental illness

n

Organisational support including professional devolvement opportunities,

mental health liaison and gaining service users’ input may help mitigate the

challenges of caring for this vulnerable patient group

732 British Journal of Nursing, 2014, Vol 23, No 13

towards improving mental health literacy, organisational

support through the use of mental health consultants and

clinical educators in acute medical settings may offer a means

to moderate ill-informed, negative and stigmatising attitudes

towards patients experiencing mental illness among cute

medical care nurses. Mental illness is profound on a global

level, and in order to suitably care for this vulnerable patient

population, hospital environments need to be conducive to

providing safe, dignified, effective and optimal care (e.g. quiet

spaces, sufficient privacy and appropriate care planning).

Understanding the mental illness experience from the service

user’s perspective can also assist in improving care provision to

this patient group and in consideration of this service users’

representation and involvement in education for nurses needs

to be a feature.

BJN

Conflict of interest: none

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Barriers and Solutions to Comprehensive Care for Mental Health Patients in Hospital Emergency Departments

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Full-text available

Apr 2024

Hospital emergency departments in Ontario, have become a common place for patients with mental health problems to seek treatment. Studies report healthcare providers have limited knowledge and competency to provide optimal care for patients with mental health problems. As a result, these patients are at risk of poor hospital experiences and treatment outcomes. In addition, emergency staff report considering patients with mental health problems lower priority to other patients. This paper reviews the existing literature and examines the challenges surrounding patients with mental health problems seeking treatment in emergency rooms and how it leads to sub-optimal care. Strategies are then shared to overcome these challenges by changing emergency department experiences for mental health patients seeking treatment.

An Exploration of Mental Health-Related Stigma in an Emergency Setting

Article

Full-text available

Jan 2024
Int J Ment Health Addiction

Mental health-related concerns are ubiquitous and deserving of the same compassion and support offered for other health problems. However, the scarcity of resources for mental health (MH) issues remains a complex public health problem. EMBER researchers sought to identify gaps in understanding of MH-related stigma in emergency departments (EDs) through interviews with (1) ED physicians/residents, nurses; (2) ED psychiatric physicians/residents, nurses; (3) protective services staff; and (4) patients and family members/support persons. Nine focus groups and 26 interviews were conducted with a total of 46 participants. Interviews/focus groups were coded using thematic analysis through research team discussion. Findings demonstrated structural stigma is a major barrier to accessing quality healthcare services and a key driver of interpersonal and intrapersonal stigma. Sustained, integrated interventions are needed to address key inequities, particularly in the model of care and service delivery, the culture of caring, in staff training, and in the ED physical space. Building trauma and resiliency-informed models of care was identified as an important foundational step in this process.

The Effectiveness of Interventions on Improving the Mental Health Literacy of Health Care Professionals in General Hospitals: A Systematic Review of Randomized Controlled Trials

Article

Aug 2023
J Am Psychiatr Nurses Assoc

Background: Suboptimal mental health literacy levels among general hospital health care professionals negatively impact the care coordination of patients with physical-mental comorbidity. Aims: This review is to examine the evidence on the effectiveness of interventions to improve the mental health literacy of general hospital health care professionals. Methods: A systematic search of literature was conducted in 13 electronic databases with manual searching of reference lists from 1980 to 2021. Studies were screened by pre-set eligibility criteria, that is, participants who were general hospital health care professionals taking care of adult patients, the interventions aimed at improving any components of participants' mental health literacy, comparisons were alternative active intervention or no intervention, and the primary outcomes were any aspects of mental health literacy. Results: Eight randomized controlled trials (N = 1,732 participants) were included in this review. Evidence indicated that mental health literacy interventions with educational components can improve components of the health care professionals' mental health literacy, in terms of mental health knowledge and mental illness-related attitudes/stigma. In addition, few studies evaluated all components of participants' mental health literacy. Conclusions: Based on the available evidence, educational interventions had a positive effect on components of general hospital health care professionals' mental health literacy. Health care organizations should provide educational programs to enhance general hospital health care professionals' mental health literacy. Further studies are needed to explore interventions that target all components of general hospital staff's mental health literacy and to evaluate its impact on the psychiatric consultation-liaison service utilization in general hospitals, as well as patient outcomes.

Caring for critically ill patients with a mental illness: A discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity

Article

Full-text available

Jul 2023

Aim: To address the need for additional education in the management of mental illness in the critical care setting by providing a broad overview of the interrelationship between critical illness and mental illness. The paper also offers practical advice to support critical care staff in managing patients with mental illness in critical care by discussing two hypothetical case scenarios involving aggressive and disorganised behaviour. People living with mental illness are over-represented among critically unwell patients and experience worse outcomes, contributing to a life expectancy up to 30 years shorter than their peers. Strategic documents call for these inequitable outcomes to be addressed. Staff working in intensive care units (ICUs) possess advanced knowledge and specialist skills in managing critical illness but have reported limited confidence in managing patients with comorbid mental illness. Design & methods: A discursive paper, drawing on clinical experience and research of the authors and current literature. Results: Like all people, patients with mental illnesses draw on their cognitive, behavioural, social and spiritual resources to cope with their experiences during critical illness. However, they may have fewer resources available due to co-morbid mental illness, a history of trauma and social disadvantage. By identifying and sensitively addressing patients' underlying needs in a trauma-informed way, demonstrating respect and maximising patient autonomy, staff can reduce distress and disruptive behaviours and promote recovery. Caring for patients who are distressed and/or display challenging behaviours can evoke strong and unpleasant emotional responses. Self-care is fundamental to maintaining a compassionate approach and effective clinical judgement. Staff should be enabled to accept and acknowledge emotional responses and access support-informally with peers and/or through formal mechanisms as needed. Organisational leadership and endorsement of the principles of equitable care are critical to creation of the environment needed to improve outcomes for staff and patients. Relevance to clinical practice: ICU nurses hold an important role in the care of patients with critical illnesses and are ideally placed to empower, advocate for and comfort those patients also living with mental illness. To perform these tasks optimally and sustainably, health services have a responsibility to provide nursing staff with adequate education and training in the management of mental illnesses, and sufficient formal and informal support to maintain their own well-being while providing this care. Patient and public involvement: This paper is grounded in accounts of patients with mental illness and clinicians providing care to patients with mental illness in critical care settings but there was no direct patient or public contribution.

Interventions and management on multimorbidity: An overview of systematic reviews

Article

Mar 2023
AGEING RES REV

Background Multimorbidity poses an immense burden on the healthcare systems globally, whereas the management strategies and guidelines for multimorbidity are poorly established. We aim to synthesize current evidence on interventions and management of multimorbidity. Methods We searched four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews). SRs on interventions or management of multimorbidity were included and evaluated. The methodological quality of each SR was assessed by the AMSTAR-2 tool, and the quality of evidence on the effectiveness of interventions was assessed by the grading of recommendations assessment, development and evaluation (GRADE) system. Results A total of 30 SRs (464 unique underlying studies) were included, including 20 SRs of interventions and 10 SRs summarizing evidence on management of multimorbidity. Four categories of interventions were identified: patient-level interventions, provider-level interventions, organization-level interventions, and combined interventions (combining the aforementioned two or three- level components). The outcomes were categorized into six types: physical conditions/outcomes, mental conditions/outcomes, psychosocial outcomes/general health, healthcare utilization and costs, patients’ behaviors, and care process outcomes. Combined interventions (with patient-level and provider-level components) were more effective in promoting physical conditions/outcomes, while patient-level interventions were more effective in promoting mental conditions/outcomes and psychosocial outcomes/general health. As for healthcare utilization and care process outcomes, organization-level and combined interventions (with organization-level components) were more effective. The challenges in the management of multimorbidity at the patient, provider and organizational levels were also summarized. Conclusion Combined interventions at different levels would be favored to promote different types of health outcomes. Challenges exist in the management at the patient, provider, and organization levels. Therefore, a holistic and integrated approach of patient-, provider- and organization- level interventions is required to address the challenges and optimize care of patients with multimorbidity.

Psychometrics of the Physical Health Attitude Scale in Taiwanese mental health nurses: A validation study

Preprint

Full-text available

Sep 2022

Background The Physical Health Attitude Scale (PHASe) is a reliable and valid scale for assessing mental health nurses’ attitude towards providing physical healthcare to patients diagnosed with serious mental illness. Aims To psychometrically evaluate the Chinese adaptation of the PHASe. Methods A total of 520 mental health nurses from 11 hospitals across Taiwan participated in this study. Brislin’s translation model was utilized for the validation process. Both exploratory factor analysis and confirmatory factor analysis were used to establish the construct validity of the scale, and Cronbach’s alpha and composite reliability were used to determine reliability. Results The four-factor 17-item Chinese version of the PHASe demonstrated satisfactory fit with significant factor loadings. Each factor had adequate internal consistency (Cronbach's alpha = 0.70 to 0.80). Known-group validity was supported by the significant differences between groups with different attitudes. Conclusions Our findings suggest that the Chinese version of PHASe is acceptable for evaluating nurses’ attitude towards providing physical health care both within culturally Chinese societies and in cross-cultural studies.

Defining the concept of mental dysregulation in patients requiring ambulance and/or emergency department care: protocol for a Delphi consensus study

Article

Full-text available

Jan 2024

Introduction From the patient and staff perspective, care delivery for patients experiencing a mental health problem in ambulance and emergency department (ED) settings is challenging. There is no uniform and internationally accepted concept to reflect people with a mental health problem who require emergency care, be it for, or as a result of, a mental health or physical health problem. On initial presentation to the emergency service provider (ambulance or ED), the cause of their healthcare condition/s (mental health and/or physical health) is often initially unknown. Due to this (1) the prevalence and range of underlying causes (mental and/or physical) of the patients presenting condition is unknown; (2) misattribution of physical symptoms to a mental health problem can occur and (3) diagnosis and treatment of the initial somatic complaint and cause(s) of the mental/physical health problem may be hindered. This study will name and define a new concept: ‘mental dysregulation’ in the context of ambulance and ED settings. Methods and analysis A Delphi study, informed by a rapid literature review, will be undertaken. For the literature review, a steering group (ie, persons with lived experience, ED and mental health clinicians, academics) will systematically search the literature to provide a working definition of the concept: mental dysregulation. Based on this review, statements will be generated regarding (1) the definition of the concept; (2) possible causes of mental dysregulation and (3) observable behaviours associated with mental dysregulation. These statements will be rated in three Delphi rounds to achieve consensus by an international expert panel (comprising persons with lived experience, clinicians and academics). Ethics and dissemination This study has been approved by the Medical Ethical Committee of the University of Applied Sciences Utrecht (reference number: 258-000-2023_Geurt van der Glind). Results will be disseminated via peer-reviewed journal publication(s), scientific conference(s) and to key stakeholders.

Interventions to reduce interpersonal stigma towards patients with a mental dysregulation for ambulance and emergency department healthcare professionals: review protocol for an integrative review

Article

Full-text available

Nov 2023

Introduction Worldwide, there is an increase in the extent and severity of mental illness. Exacerbation of somatic complaints in this group of people can result in recurring ambulance and emergency department care. The care of patients with a mental dysregulation (ie, experiencing a mental health problem and disproportionate feelings like fear, anger, sadness or confusion, possibly with associated behaviours) can be complex and challenging in the emergency care context, possibly evoking a wide variety of feelings, ranging from worry or pity to annoyance and frustration in emergency care staff members. This in return may lead to stigma towards patients with a mental dysregulation seeking emergency care. Interventions have been developed impacting attitude and behaviour and minimising stigma held by healthcare professionals. However, these interventions are not explicitly aimed at the emergency care context nor do these represent perspectives of healthcare professionals working within this context. Therefore, the aim of the proposed review is to gain insight into interventions targeting healthcare professionals, which minimise stigma including beliefs, attitudes and behaviour towards patients with a mental dysregulation within the emergency care context. Methods and analysis The protocol for a systematic integrative review is presented, using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols recommendations. A systematic search was performed on 13 July 2023. Study selection and data extraction will be performed by two independent reviewers. In each step, an expert with lived experience will comment on process and results. Software applications RefWorks-ProQuest, Rayyan and ATLAS.ti will be used to enhance the quality of the review and transparency of process and results. Ethics and dissemination No ethical approval or safety considerations are required for this review. The proposed review will be submitted to a relevant international journal. Results will be presented at relevant medical scientific conferences. PROSPERO registration number CRD42023390664 ( https://www.crd.york.ac.uk/prospero/ ).

Experiences of psychiatric nurses caring for mental healthcare users with a comorbid disorder

Article

Full-text available

Dec 2022
Curationis

Background: Caring for mental healthcare users (MHCUs) with a comorbid disorder of human immunodeficiency virus (HIV) and schizophrenia has always been challenging and requires expertise, skill, intuition and empathy. Objectives: The objective of this study was to explore and describe the experiences of psychiatric nurses caring for MHCUs with a comorbid disorder of HIV and schizophrenia. Method: A qualitative, exploratory, descriptive and contextual research design was used. Eight participants were selected through purposive sampling for individual in-depth interviews to collect data. Thematic analysis was used to analyse data. Results: Three themes emerged from this study. The first theme is that the psychiatric nurses experienced deep frustration because they were capable but unable to manage MHCUs with HIV and schizophrenia because of poor infrastructure and other contributing barriers. The second theme identified that the psychiatric nurses experienced discrimination against MHCUs compromising their holistic recovery. Lastly, the psychiatric nurses identified the need for health care workers in general hospitals and communities and families of MHCUs with a comorbid disorder to be educated in mental health issues to ensure continuous medical care. Conclusion: The results of this study showed that psychiatric nurses became exhausted when trying to cope with difficult nursing situations. The challenges they faced had negative consequences for the mental health of the psychiatric nurses and compromised patient care. Contribution: This study adds knowledge to nursing practice, nursing education and nursing research by implementing recommendations to mitigate the challenges of psychiatric nurses caring for MHCUs with HIV and schizophrenia.

Stigma towards patients with mental illness: An online survey of United States nurses

Article

Oct 2022

People with mental illness experience significant health disparities, including morbidity and premature mortality. Evidence suggests that stigma is a contributing factor to these observed inequities. The tripartite conceptualization of stigma proposes that three problems underlie stigma: problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination). There is limited prior research concerning stigma towards mental illness among nurses in the United States (US). The aims of this study were to assess stigma among US nurses towards patients with mental illness, compare the stigma expressed by nurses working in medical/surgical settings with mental health settings, and identify factors associated with stigma. Participants were recruited online from national professional nursing organizations in the US. We collected demographic data and administered measures of mental health stigma and stigma‐related mental health knowledge. Mental health nurses demonstrated comparatively lower levels of stigma and higher levels of knowledge than the medical/surgical nurses. Nursing speciality and personal contact with mental illness were the most significant predictors of stigma and knowledge. Knowledge was found to partially mediate the relationship between nursing speciality and stigma. We found support for the ‘contact hypothesis’, that is, having a personal experience of mental illness or a friend or family member who has a mental illness is associated with lower stigma towards mental illness. These findings support the development of contact‐based and educational anti‐stigma interventions for nurses in order to reduce stigma towards mental illness.

Enhanced physical health screening for people with severe mental illness in Hong Kong: Results from a one-year prospective case series study

Article

Full-text available

Feb 2014
BMC PSYCHIATRY

People with severe mental illness have significantly poorer physical health compared to the general population; previous health screening studies conducted outside Asian countries have demonstrated the potential in addressing this issue. This case series aimed to explore the effects and utility of integrating an enhanced physical health screening programme for community dwelling patients with severe mental illness into routine clinical practice in Hong Kong. This study utilises a consecutive prospective case series design. The serious mental illness Health Improvement Profile (HIP) was used as a screening tool at baseline and repeated at 12 months follow-up. A total of 148 community-based patients with severe mental illness completed the study. At one year follow-up analysis showed a significant improvement in self-reported levels of exercise and a reduction in the numbers of patients prescribed medications for diabetes However, mean waist circumference increased at follow-up. In addition to the statistically significant results some general trends were observed, including: a lack of deterioration in most areas of cardiovascular risk; a reduction in medicines prescribed for physical health problems; and general improvements in health behaviours over the 12 month period. The findings demonstrate that using the HIP is feasible and acceptable in Hong Kong. The results of the enhanced physical health-screening programme are promising, but require further testing using a randomised controlled trial design in order to more confidently attribute the improvements in well-being and health behaviours to the HIP.Trial registration: Clinical trial registration number: ISRCTN12582470.

Sri Lankan doctors’ and medical undergraduates’ attitudes towards mental illness

Article

Full-text available

Jul 2010

Background: Stigmatizing attitudes towards mental illness can impede help-seeking and adversely affect treatment outcomes, especially if such attitudes are endorsed by medical personnel. In order to help identify targets for anti-stigma interventions, we comprehensively examined negative attitudes towards mental illness displayed by Sri Lankan doctors and medical students and compared these with equivalent UK and other international data. Method: A self-report questionnaire originally developed in the UK was completed by medical students (n = 574) and doctors (n = 74) from a teaching hospital in Colombo. The questions assessed the presence and intensity of stigmatizing attitudes towards patients with schizophrenia, depression, panic disorder, dementia and drug and alcohol addiction. Results: The study revealed higher levels of stigma towards patients with depression, alcohol and drug addiction in this Sri Lankan sample compared to UK data but attitudes towards schizophrenia were less stigmatized in Sri Lanka. Blaming attitudes were consistently high across diagnoses in the Sri Lankan sample. Sri Lankan medical students displayed more negative attitudes than doctors (P < 0.001). Overall stigma was greatest towards patients with drug addiction, followed by, alcohol addiction, schizophrenia, depression, panic disorder and dementia. Conclusions: Sri Lankan doctors and undergraduates endorse stigmatizing attitudes towards mental illnesses and are especially prone to see patients as blameworthy. As such attitudes are likely to affect the engagement of patients in treatment and specific interventions that modify negative attitudes towards people with mental illnesses are needed. Ensuring that medical students have contact with recovered patients in community psychiatry settings may be one way of decreasing stigmatizing attitudes.

A Medical-Surgical Nurse's Perceptions of Caring for a Person With Severe Mental Illness

Article

Full-text available

Jun 2012
J Am Psychiatr Nurses Assoc

When hospitalized for medical conditions, many people with severe mental illness (SMI) have poor outcomes, yet little is known about contributing factors. Studies exploring the care experience from nurses' perspectives described care processes as "difficult." None of these studies were conducted in the United States, and sociocultural contexts significantly affect perceptions of SMI. The purpose of this inquiry was to explore a medical-surgical nurse's perceptions of caring for a hospitalized person with SMI in the United States. Design: A qualitative, descriptive case study was used. The nurse's experience was characterized by categories of tension, discomfort, lack of professional satisfaction, and difficult. This case study revealed a negative care experience, similar to conclusions of investigations conducted in other countries. Understanding of nurses' care experiences can inform efforts to improve practice environments, provide resources, or develop models of care that support nurses who care for patients with SMI and improve health outcomes for people with SMI.

Attitudes of healthcare professionals towards psychiatric patients in a general hospital in Hong Kong

Article

Mar 2007

Objectives: To examine the attitudes of healthcare professionals towards psychiatric patients in a general hospital in Hong Kong, and explore what contributions these attitudes may have on their management. Participants and Methods: A survey was carried out on healthcare professionals working in a general hospital in Hong Kong. A newly devised questionnaire with a case vignette was used. Each subject received a case depicting either a psychiatric patient (case group) or a diabetes mellitus patient (control group) randomly. Results: A total of 1200 questionnaires were distributed with a response rate of 36.1%. A case vignette depicting a psychiatric patient elicited responses that reveal a statistical significant contribution towards the expression of negative opinions; about two-thirds of the statements contained negative connotations. Increase in social exposure to psychiatric patients led to a decrease in negative attitude, whilst negative experience with psychiatric patients led to an increase in negative attitude. Conclusion: Stigma towards psychiatric patients exists to a certain degree among the healthcare professionals in the general hospital we investigated. More clinical research is needed in this area to have a more in-depth understanding of the issue.

Emergency Room Psychiatric Services: A Qualitative Study of Nurses’ Experiences

Article

Apr 2013
Issues Ment Health Nurs

Emergency nurses working in general emergency divisions (EDs) are primarily trained to assess and treat acute physical problems. However, ED nurses often care for psychiatric patients and the perceptions of nurses in EDs regarding their experiences with psychiatric patients have not been well-studied. Using focus groups, the purpose of this study was to explore and describe ED nurses' experiences, and feelings caring for patients with mental illness. Krueger and Casey's qualitative analysis for focus groups was utilized to code and categorize phrases and identify themes from transcribed interviews. Four themes emerged; powerlessness best captured the overarching and substantive experience of the participants. Based on the findings, implications for emergency room care of psychiatric patients are described.

Attitude Disentangled: A Cross-Sectional Study into the Factors Underlying Attitudes of Nurses in Dutch Rehabilitation Centers toward Patients with Comorbid Mental Illness

Article

Feb 2013
Issues Ment Health Nurs

In rehabilitation centers, many patients suffer a comorbid mental illness. Nurses have different attitudes toward these patients. A cross-sectional, questionnaire-based study among nurses in Dutch rehabilitation centers was undertaken to clarify the factors that underlie attitudes toward patients with comorbid mental illness. The main factors associated with attitudes were feelings of competence and experiences with dealing with patients with mental illness. Other associations were perceived support; frequency of caring for patients with comorbid mental illness; work experience in mental health care; additional psychiatric training; and the personality traits "extraversion," "emotional stability," and "openness to experience." Perceived support had the strongest association with feelings of competence.

Increased prevalence of chronic physical health disorders in Australians with diagnosed mental illness

Article

Oct 2012
AUST NZ J PUBL HEAL

Objective: To compare chronic physical health disorder prevalence amongst Australian adults with and without mental illness. Method: Total n=1,716 participants (58% female) with a mean age of 52 ± 13 years (range: 18 to 89 years) completed an online survey of Australian adults in 2010. Outcome measures including prevalence of chronic physical conditions and self-reported body mass index (BMI) in n=387 (23%) with a self-reported mental illness diagnosis were compared to respondents without mental illness. Results: A significantly higher proportion of participants with mental illness were obese (BMI ≥ 30; 31 vs 24%, p=0.005). Adjusted odds ratios (OR) for coronary heart disease, diabetes, chronic bronchitis or emphysema, asthma, irritable bowel syndrome, and food allergies or intolerances (OR range: 1.54–3.19) demonstrated that chronic physical disorders were significantly more common in participants with a mental illness. Conclusion: Australian adults with a diagnosis for mental illness have a significantly increased likelihood of demonstrating chronic physical health disorders compared to persons without mental illness. Implications: Health professionals must be alert to the increased likelihood of comorbid chronic physical disorders in persons with a mental illness and should consider the adoption of holistic approaches when treating those with either a mental or physical illness.

Factors contributing to difficulty with psychiatric disorder among junior medical staff

Article

Aug 2002
AUSTRALAS PSYCHIATRY

Ann Solar

Objective: This study examines the attitudes and difficulties that junior medical staff, working in the emergency department of a teaching hospital, have in relation to psychiatric disorders.Method: Systematic textual analysis of nine in-depth interviews.Results: Three major categories identified were emotional difficulty with patient interaction, uncertainty and pessimism.Conclusion: Those doctors able to self reflect and adjust their level of emotional distance appropriately had less emotional difficulty interacting with psychiatric patients. They were also more comfortable in dealing with the issue of uncertainty associated with psychiatric disorder. There was a worrying level of pessimism regarding prognosis in psychiatric disorder.

A systematic review of the critical appraisal skills training for clinicians

Article

Feb 2000
MED EDUC

The aim of this paper is to undertake a descriptive systematic review of the effectiveness of critical appraisal skills training for clinicians. Of the 10 controlled studies which examined this issue and were found to meet the eligibility criteria of this review, all used a study population of either medical students or doctors in training. The studies used a variety of different intervention ‘dosages’ and reported a range of outcomes. These included participants’ knowledge of epidemiology/biostatistics, their attitudes towards medical literature, their ability to appraise medical literature, and medical literature reading behaviour. An overall improvement in assessed outcomes of 68% was reported after critical appraisal skills training, particularly in knowledge relating to epidemiology and biostatistics. This review appears to provide some evidence of the benefit of teaching critical appraisal skills to clinicians, in terms of both knowledge of methodological/statistical issues in clinical research and attitudes to medical literature. However, these findings should be considered with caution as the methodological quality of studies was generally poor, with only one study employing a randomized controlled design. There is a need for educators within the field of evidence-based health to consider the implications of this review.

A risk to himself: Attitudes toward psychiatric patients and choice of psychosocial strategies among nurses in medical-surgical units

Article

Apr 2012
RES NURS HEALTH

Psychiatric patients are liable to stereotyping by healthcare providers. We explored attitudes toward caring for psychiatric patients among 13 nurses working in general hospitals in Ireland. Participants thought aloud in response to a simulated patient case and described a critical incident of a patient for whom they had cared. Two attitudinal orientations were identified that correspond to stereotypical depictions of risk and vulnerability. The nurses described psychosocial care strategies that were pragmatic rather than authentically person-centered, with particular associations between risk-oriented attitudes and directive nursing care. Nurses had expectations likely to impede relationship building and collaborative care. Implications arising include the need for improved knowledge about psychiatric conditions and for access to professional development in targeted therapeutic communication skills.

Challenges in acute care of people with co-morbid mental illness

Abstract

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