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Improving care for clients with a severe mental illness

This summary relates to the role of the Mental Health Nurse (MHN) in the physical health of people diagnosed with severe mental illness in the context of the RCN’s Parity of Esteem work programme. 

The scope covers the role specifics, what may work in reducing the mortality gap, the skills and resources MHNs need and the systems are in place to enable them to work effectively.

The dangers of poor physical health have been known for a number of years; there remains a significant level of concern over the health inequalities that continue to be experienced by those diagnosed with severe mental illness. 

Research has identified the main role of the MHN as one of assessment and monitoring the physical health care of clients diagnosed with severe mental illness, but a number of issues have been raised around how systems equip and support MHN to fulfil this role.

Research cites lack of knowledge and skills, systemic issues linked to fragmentation of services, lack of training and education, and lack of polices and guidance for practice. In addition, there is a requirement to focus training on the individual and social determinants of health that contribute to the poor physical health of those with SMI.
15-20 The number of years of life lost among those diagnosed with SMI

Incentives

Research exploring the user perspective revealed that professionals often fail to view clients holistically despite the link between mental and physical health. Users viewed losing weight as the single most important motivator for attending lifestyle interventions identified by users, and identified the importance of peer and staff support, and building relationships, and they valued the environment, context and the role and characteristics of the healthcare professional delivering key lifestyle interventions.

From a provider perspective, incentives have been identified as increased knowledge and skills, facilitated through the provision of post-registration training, improvements in the quality of patient care, and increased morale and job satisfaction for nurses. In the context of wider society any decrease in the mortality of those diagnosed with severe mental illness lies in the reduction of inequalities and disparities in service provision, and the enhancement of the human rights of this section of the population.

Barriers

System related barriers identified included the separation of physical and mental health services leading to fragmentation of services. Organisation level barriers include a continued emphasis on the biomedical model which focuses on ill-health rather than health promotion, diagnostic overshadowing, and continued stigma associated with mental illness.

Individual level barriers include professional attitudes, client behaviour and lifestyle choices, and user non-compliance with advice on medication. Diagnostic overshadowing is identified as significant, with the factors contributing to it include poor communication, client behaviour, overcrowding and noise in the emergency department, and the stigmatising attitudes of staff. Another barrier is the lack of consensus regarding the frequency and type of monitoring required, and although guidelines and policies exist, these are not always implemented.

Proposed Solutions

Proposed solutions have been identified on a continuum of system, organisation and individual levels. At the system level these include the re-integration of physical and mental health services. Organisation level solutions include the provision of post-registration training and education and the introduction of specialist nurses into mental health settings. At the organisation and individual level, proposed solutions include the use of checklists and tools, the implementation of guidelines and policies, and a greater emphasis on health promotion intervention

The integration of physical and mental health services could be facilitated through better co-ordination and active engagement with the physical health of patients with mental illness through the development of GP-led clinics with health community teams attached to them. This would facilitate greater involvement of psychiatrists and the development of shared care to establish full integration between physical and mental health services.

Another solution is the provision of specialist nurses in mental health settings to support MNHs to assess and monitor the physical healthcare needs of their client population, where MHNs work more closely with their colleagues in general health settings. In addition, nurses identified a need for a more robust inclusive system, where clear guidance, information and policies are easily accessible. Other solutions have been identified as checklists and tools, including the Health Improvement Profile (HIP).