YAPNU-50966; No of Pages 7

Archives of Psychiatric Nursing xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence,
Barriers and Psychological Empowerment
Margaret Knight a,⁎, Paula Bolton b, Lynne Kopeski c
a
School of Nursing, University of Massachusetts Lowell, Lowell, MA, United States
b
Psychiatric Neurotherapeutics Program, McLean Hospital, Belmont, MA, United States
c
Behavioral Health Partial Hospital Program, McLean Hospital, Belmont, MA, United States

a r t i c l e i n f o a b s t r a c t

Article history: The prevalence of metabolic syndrome (MetS) in people with serious mental illness (SMI) has been well docu-
Received 20 March 2017 mented in the mental health literature. Despite the adoption of various guidelines for monitoring risk factors
Revised 21 June 2017 for diabetes and cardiovascular risk in this population, limited translation has occurred in actual practice (Her-
Accepted 7 July 2017
mes, Sernyak, & Rosenheck, 2013). The Institute of Medicine (IoM) (2009) has noted a lag time in the application
Available online xxxx
of knowledge within clinical settings. Evidence-based practice was deemed as a means of improving healthcare
outcomes through the use of science supported standards of care. Evidence-based practice (EBP) is a process to
guide clinical decision making that involves the clinician's experience, well documented research findings, and
the patient's values and choices (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). The IoM has established
that by the year 2020, 90% of clinical decisions should be based upon current and scientifically based information
(IoM, 2009). Psychiatric-mental health nurses are challenged to utilize EBP for clients with MetS in assessing
their health status and discussing the findings, educating them about their current risk and life style modifica-
tions to mitigate risk, and finally, partnering with them to maximize health and quality of life.
© 2017 Elsevier Inc. All rights reserved.

BACKGROUND AND LITERATURE REVIEW (Centorrino, Masters, Talamo, Baldessarini, & J., & Ongur, D., 2012;
Coakley et al., 2012). Despite the fact that many of these risk factors
There is a growing call for integrated care for patients with serious may be amenable to interventions such as weight loss programs, exer-
mental illness (SMI). Mental health and physical health both contribute cise regimens, smoking cessation and medication adjustments, the nec-
to a sense of well-being and this is increasingly being recognized by the essary monitoring to identify the issues and subsequent treatment
health care community. Too often clinicians focus on their specialty, be options are never fully addressed by members of the health care team,
that mental health or physical disease, and forget to address the needs including psychiatric-mental health nurses. Often it is the development
of the whole person. This is especially true for persons with SMI who of a cardiovascular or metabolic complication that prompts monitoring
live, in general, many years less than people in the general population and/or treatment (Barnes, Bhatti, & Adroer, 2015).
(Manderscheid et al., 2010). Psychiatric-mental health nurses, at all levels of health care, are in
Contributing to the health problems for persons with SMI are the de- position to positively impact the monitoring for risk factors for MetS,
veloping metabolic risk factors for cardiovascular disease and diabetes. the patient education to increase the person with SMI's awareness of
Perhaps due to genetic factors, lifestyle behaviors or medication side ef- these risks, and the implementation of risk reduction strategies to pre-
fects, persons with SMI are more at risk to develop metabolic syndrome vent development of disease. The knowledge of risk factors and moni-
(MetS), a set of factors which increase the risk of developing diabetes toring related to MetS appears to be good among psychiatric mental
and its complications as well as cardiovascular conditions. According health nursing clinicians yet implementation into practice is slow
to the American Diabetes Association, MetS is present when three of (Bolton, Knight, & Kopeski, 2016).
the following five risk factors exist: increased fasting blood glucose, el- The question of who is responsible for the detection, monitoring and
evated blood pressure, decreased high density lipoprotein levels, in- treatment interventions of the person with SMI and MetS has been
creased triglyceride levels and increased waist circumference. Studies discussed throughout the literature. Frequently, mental health pro-
of persons with SMI have shown an increased prevalence of MetS viders cite a lack of expertise as well as limited time and resources in
accessing ongoing medical care (Dixon et al., 2007). A recent study
⁎ Corresponding author. which provided a course on physical health issues in mental health
E-mail address: [email protected] (M. Knight). practice to psychiatric-mental health nurses reported an increased

http://dx.doi.org/10.1016/j.apnu.2017.07.001
0883-9417/© 2017 Elsevier Inc. All rights reserved.

Please cite this article as: Knight, M., et al., Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and
Psychological Empowerment, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.07.001
2 M. Knight et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx

confidence in assessment skills, but did not reflect an increase confi- theory, positions with formal power are prominent, essential to the mis-
dence in the application to their clinical practice (Terry & Cutter, 2013). sion of the organization, and permit discretion in decision making. In-
Conversely, Mangurian et al. (2013) reported in a study of primary formal power stems from relationships among co-workers to facilitate
care providers, that 40% were unaware of guidelines for patients on sec- completing the work (Kanter, 1993). Laschinger (1996) described
ond generation antipsychotics. The primary care providers identified Kantor's theory of Structural Power in relation to nurses' work environ-
obstacles for monitoring risk factors for Met S including the degree of ments, and Purdy, Laschinger, Finegan, Kerr, and Olivera (2010) note
psychiatric illness, the dilemma of working with psychiatrists and the that the lack of empowerment in workplace settings impacts patient
complexities of planning mental health outpatient care. Overall, better satisfaction, nurse satisfaction and nurse retention.
coordination is needed between primary care and mental health pro- Empowered employees need access to resources in order to fulfill
viders in determining who is responsible for monitoring metabolic their responsibilities. A comprehensive literature review on workplace
parameters. empowerment and nurses' job satisfaction reported that an empowered
Nash (2014) conducted a small qualitative study of mental health workplace promoted a professional practice environment, enhanced job
service users' perception of diabetes care received within the mental satisfaction and affirmed the caliber of patient care (Cicolini,
health system. Identified factors which impeded treatment were stig- Comparcini, & Simonetti, 2014). Laschinger, Gilbert, Smith, and Leslie
ma, the attribution of physical symptoms to mental illness, delay in di- (2010) proposed a nurse/patient empowerment model that suggests
agnosis of diabetes while exhibiting symptoms which required a when nurses are empowered within their work environment with ac-
medical hospitalization, and lack of coordination between physical cess to support, information and resources, they in turn empower
and mental health services. The study participants noted that although others, including their patients. While structural empowerment within
mental health nurses were knowledgeable, there appeared to be a lim- organizations has been described as a significant factor related to em-
ited ability of the nurses to translate practical interventions for diabetes ployee behavior, the need for nurses to be empowered to make deci-
care. This important study further reported that inpatient mental health sions, developing the blueprint for their work environment and
nurses endorsed the value of physical health assessment of persons opportunities for professional growth and development were identified
with SMI and viewed this as a function of their roles. However, there as essential elements for enhancing patient safety, (IoM, 2004). Nurses
was a range in their confidence scores from being very confident for need to be able to manage their practice. This has been recognized by
obtaining vital signs, weight measurement and glucose checks to a less- the profession over the last several decades.
er confidence level with reviewing physical and mental health histories Being empowered to direct ones' practice activities can also impact
and lifestyle patterns. They reported no confidence in their ability to re- patient care. Menon defined psychological empowerment as “a cogni-
view laboratory results. tive state characterized by a sense of perceived control, competence
The literature supports that nurses are knowledgeable regarding the and goal internalization” (Menon, 2001, p.159). The focus is on the
need for physical assessment in the person with SMI, however this as- employee's experience of empowerment based upon enabling strate-
sessment is often not being implemented within their practice (Bolton gies implemented by the organization. The three empowering compo-
et al., 2016; Howard & Gamble, 2011). Howard and Gamble (2011) fur- nents are a sense of perceived control, which fosters an ability to
ther report that while valuing physical health screening and assess- influence ones' work environment, perceived competence whereby
ments, nursing documentation in the medical record did not reflect one believes they are capable to meet the work demands, and lastly,
this. Barriers within the workplace that may be affecting the psychiat- goal internalization of adopting the vision and values of the organiza-
ric-mental health nurse's ability to fulfill their role in health screening tion (Menon, 2001).
and assessment need to be evaluated. Laschinger, Finegan, and Wilk (2009) noted the working relation-
A Swedish study reported that mental health workers endorsed and ship between the nurse manager and nursing staff is crucial in fostering
valued the use of EBP, however there was a reduction in the ability and/ an empowering practice environment. The nurse manager facilitates ac-
or readiness to incorporate the evidence in their actual practice cess to resources for goal attainment, sets the professional tone of the
(Engström, Jacobson, & Martensson, 2015). The adoption of EBP is environment, and supports decision making for patient care; in this
significant for nursing and the mandate to integrate best practices study, structural empowerment supported psychological empower-
into clinical decision making is essential (Stevens, 2013). The transfer ment. Wang and Liu (2015) discussed the impact of psychological em-
of evidenced-based research to practice is facilitated through the use powerment as a means of increasing the nurses' confidence in their
of clinical guidelines for the nurse to tailor to the individual's need. ability and knowledge to accomplish their work. For example, the inte-
Majid et al. (2011) reported 64% of nurses reported positive attitudes gration of new graduate mental health nurses into the work environ-
toward EBP however barriers within the workplace impeded their ment is influenced by the relationships between senior nurses and the
application to practice. The barriers to using EBP cited by nurses multidisciplinary team. This opportunity for dialogue provides an
included a lack of time due to caseloads and staffing shortages, diffi- empowering supportive learning environment, which fosters profes-
culty accessing resources, and limited support (Majid et al., 2011; sional growth and confidence in the mental health nurse (Wright,
Melnyk et al., 2004). Lavoie-Tremblay, Drevniok, Racine, & Savignac, 2011).
Other authors have noted organizational barriers such as time con-
straints, perception of not being able to change one's practice, insuffi-
cient knowledge and skills related to EBP, lack of mentors, and lack of PURPOSE
resources and support from administration (Gerrish & Clayton, 2004;
Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2009). Additional In a previous study the researchers noted that mental health nurses
barriers not previously reported by nurses were unavailable informa- knowledge of the evidence regarding metabolic risks and related mon-
tion and opposition from other nurses, physicians and nurse managers itoring and treatment of persons with SMI did not translate well into
(Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). These practice (Bolton et al., 2016). Therefore, this study sought to explore at-
cited barriers point to how the cultural norms of an organization can im- titudes, confidence and barriers in providing physical health care for
pact practice. persons with SMI who are at risk for or are experiencing Met S and if at-
Kanter's (1993) theory of Structural Power explains how employee titudes, confidence and barriers were related to whether physical care
behaviors may be more influenced by work place conditions rather activities were routinely conducted in practice. Finally, we explored
than personal characteristics. Kanter details that the role of power and whether nurses' perceived psychological empowerment or ability to in-
the capability to get the work done originates from structural conditions fluence practice related to Met S in their workplace was related to the
and not the individual attributes of the employee. According to this performance of physical care activities.

Please cite this article as: Knight, M., et al., Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and
Psychological Empowerment, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.07.001