Running head: BARRIERS TO DIABETIC EDUCATION
BARRIERS TO MENTAL HEALTH NURSES WORKING IN COMMUNITY MENTAL
HEALTH CLINICS TO PROVIDING DIABETIC SCREENING, MONITORING, AND
EDUCATION TO PEOPLE LIVING WITH SCHIZOPHRENIA
By
JACQUELINE H. HALL, RN, BSN
A manuscript submitted in partial fulfillment of the requirements for the degree of:
MASTER OF NURSING
WASHINGTON STATE UNIVERSITY-VANCOUVER
College of Nursing
APRIL 2014
BARRIERS TO DIABETIC EDUCATION
To the faculty of Washington State University:
The members of the committee appointed to examine the Non-Thesis final project by
JACQUELINE H. HALL find it satisfactory and recommend that it be accepted.
______________________________________
Chair: Mel Haberman, PhD, RN, FAAN
______________________________________
Dawn Rondeau, DNP, ACNP, FNP
______________________________________
Melody Rasmor, Ed D (c), ARNP-BC, COHN
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BARRIERS TO DIABETIC EDUCATION
BARRIERS TO MENTAL HEALTH NURSES WORKING IN COMMUNITY MENTAL HEALTH
CLINICS TO PROVIDING DIABETIC SCREENING, MONITORING, AND EDUCATION TO
PEOPLE LIVING WITH SCHIZOPHRENIA
Abstract
By Jacqueline H. Hall, RN, BSN
Washington State University
April 2014
Chair: Mel Haberman
Schizophrenia (SMI) is a mental illness which is chronic and life-long. It is a thought disorder which
detracts from the individual’s ability to think clearly and follow logical thought patterns (Hardy & Gray,
2012). ). Between 15-30% of people living with schizophrenia have type II diabetes mellitus depending
on their age (El-Mallakh, 2006; Hardy & Gray, 2012). A challenge with the current medical system in
the United States is that the comorbidities of SMI and type II diabetes mellitus are managed primarily in
two different specialty clinic arenas: the community mental health clinic and primary care clinics (Bennett
& Manley, 1998; Happell, Scott, Platania-Phung, & Nankivell, 2012; Hultsjo & Hjelm, 2012). Mental
health nurses working at community mental health clinics are the primary contact point for people with
SMI. (MacHaffie, 2002; Miller & Martinez, 2003; Robson & Gray, 2007). Three barriers to mental health
nurses taking a more active role in screening, monitoring and educating to the diabetic SMI are (a) the
lack of clarity within the role of mental health nurses (b) the lack of diabetic training and screening tools
for mental health nurses to use in clinic, and (c) the lack of administrative support for the expansion of the
mental health nurse role in educating clients living with the co-morbid diagnoses of type II diabetes
mellitus and the SMI in the community mental health clinic setting.
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BARRIERS TO DIABETIC EDUCATION
Keywords nurse educator, nurse coordinator, nurse manager, psychiatric health, psychiatric illness, severe
mental illness, diabetes monitoring, diabetes education, primary care medicine, self-care, health
promotion, Schizophrenia.
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BARRIERS TO DIABETIC EDUCATION
TABLE OF CONTENTS
ABSTRACT……………………………………………………………………………...
iii
INTRODUCTION………………………………………………………………………..
1
DATA SOURCES………………………………………………………………………..
5
THEORETICAL FRAMEWORK………………………………………………………..
5
LITERATURE REVIEW………………………………………………………………...
7
ROLE OF THE MENTAL HEALTH NURSE…………………………………
7
DIABETIC EDUCATION TOOLS AND TRAINING…………………………
15
ADMINISTRATIVE SUPPORT………………………………………………..
20
DISCUSSION……………………………………………………………………………. 25
REFERENCES…………………………………………………………………………… 27
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BARRIERS TO DIABETIC EDUCATION
BARRIERS TO MENTAL HEALTH NURSES WORKING IN COMMUNITY MENTAL HEALTH
CLINICS TO PROVIDING DIABETIC SCREENING, MONITORING, AND EDUCATION TO
PEOPLE LIVING WITH SCHIZOPHRENIA
Purpose
Schizophrenia (SMI) is a severe mental illness which is chronic and life-long. It is a thought
disorder which detracts from the individual’s ability to think clearly and follow logical thought patterns.
The person may experience auditory, visual and other perceptual hallucinations. Delusional thoughts of
association, paranoia and inappropriate social behavior may also plague people with SMI (Hardy & Gray,
2012). According to the Diagnostic and Statistical Manual 5 (2013) SMI is defined as a psychotic
disorder characterized by “abnormalities in one or more of the following five domains: delusions,
hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior
(including catatonia), and negative symptoms,” (p. 87).
People living with SMI commonly live in unsafe, unhealthy settings, exposed to risk factors of
poor nutrition, pollution, crime, violence, unprotected sex, and other related risks to physical health, and
due to compromised cognitive faculties, may not seek preventative care and treatment when needed
(Hultsjo & Hjelm, 2012; Marion et al., 2004) According to the World Health Organization (2011), 80%
of people with SMI do not receive necessary health care services in low- and middle-income countries
(World Health Organization, 2011). Regrettably, people living with SMI also live with the risk of
increased morbidity and mortality rates, even with the exclusion of completed suicide statistics (Beebe,
2008; Druss, Von Esenwein, Compton, Zhao, & Leslie, 2011; Jensen, Decker, & Andersen, 2006;
Verhaeghe, De Maeseneer, Maes, Van Heeringen, & Annemans, 2011). It is well documented in the
literature that persons with SMI have poorer health outcomes than the rest of the adult population.
Mortality occurs 10-25 years sooner than others of comparable age, with more frequency than thirty
years ago, primarily due to complications from comorbid conditions (Bradshaw & Pedley, 2012;
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BARRIERS TO DIABETIC EDUCATION
Happell, Platania-Phung, & Scott, 2013;Hardy & Thomas, 2012; Hemingway, Trotter, Stephenson, &
Holdich, 2013; MacHaffie, 2002; Nover, 2013;Robson & Gray, 2007; Tranter, Irvine, & Collins, 2012).
At least 50% of people with SMI have diagnosed comorbid medical illnesses, and an additional
35% have undiagnosed conditions (Jensen et al., 2006; Marion et al., 2004). Three primary chronic
conditions which lead to premature death rates in the SMI are diabetes mellitus type II, hypertension, and
cardiovascular disease all of which are interconnected conditions often beginning with chronically high
blood glucose levels, indicated by HgbA1c levels greater or equal to 7% ( Casey et al., 2004; Scain, Dos
Santos, Friedman, & Gross, 2007; Tranter, Irvine, & Collins, 2012).
Diabetes mellitus type II is a chronic medical condition. It is the most common type of diabetes,
and affects every system in the body especially the nervous, cardiovascular, gastrointestinal, pancreatic,
and renal systems, as well as the visual cortex (American Diabetes Association, 2014; National Diabetes
Informational Clearinghouse, 2014). High blood pressure, blood lipid levels, and blood glucose create the
complications of cardiovascular disease, blindness, amputations, nerve damage and kidney failure.
Diabetes is costly in terms of death rates, decreases in functioning, and indirect and direct costs, which in
general terms, topped $218 billion in 2011 (Welch et al., 2011). Between 15-30% of people living with
SMI, have type II diabetes depending on their age. Interestingly, this statistic is comparable to research
compiled in the 1920’s, (well before the first antipsychotic medication was discovered) by psychiatrists
who found that 15% of people diagnosed with SMI were obese and diabetic (El-Mallakh, 2006; Hardy &
Gray, 2012). Sedentary lifestyle, high carb-high-fat diets, obesity, high stress and lack of social support
also contribute to the onset of type II diabetes mellitus. Amotivation, cravings for high-fat, high-carb
foods, and obesity are intrinsic characteristics of persons with SMI which complicate the achievement of
successful diabetic education outcomes in this population (McCardle, Parahoo, & McKenna, 2007;
Verhaeghe, De Maeseneer, Maes, Van Heeringen, & Annemans, 2011).
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BARRIERS TO DIABETIC EDUCATION
Second generation antipsychotics are effective for managing symptoms of psychosis related to
SMI, however, they are another primary risk factor for DM (Ohlsen, Peacock, & Smith, 2005). Though it
is evident SMI clients have an intrinsic propensity toward s obesity and type II diabetes mellitus, the
second generation antipsychotics leave SMI people with a higher risk of developing diabetes mellitus due
to the medications’ higher affinity towards receptor sites such as serotonin, norepinephrine, dopamine and
histamine (Ohlsen, Peacock, & Smith, 2005). The exact mechanism and role second generation
antipsychotics play in increasing risk factors for diabetes mellitus is unknown, but blocking these receptor
sites, can increase appetite, aphysical behavior, increase amotivation and apathy, and place the SMI at
higher risk for glucose intolerance and type II diabetes (Blythe & White, 2012; Hultsjo & Hjelm, 2012).
Increases in adrenalin, due to the stress of chronic psychosis and poor living situations, can also possibly
be related to increased glucose levels and dysregulation, and therefore, a higher risk of obesity (ElMallakh, 2006). Insulin resistance, pancreatic beta cell failure, and hyperglycemia are all characteristics
of what is known as metabolic syndrome, which is indicated in a person’s unhealthy weight gain; weight
gain is an antecedent to type II diabetes mellitus (Hemingway, Trotter, Stephenson, & Holdich, 2013;
Ohlsen, Peacock, & Smith, 2005). According to Bradshaw and Pedley (2012) “substantial weight gain
over the first year in first-episode psychotic patients prescribed one to three commonly used
antipsychotics ranging from 4kg for Haldol, to 16.8 kg for Zyprexa,” (p. 267). Glucose, insulin
resistance, insulin levels and cholesterol, were noted to increase in as little as 8 weeks, and by 12 months,
insulin measurements and resistance, lipid levels, leptin, and ghrelin levels were also noted to increase
(Bradshaw & Pedley, 2012). Weight gain, induced by second generation antipsychotics, has been a cause
of SMI clients’ non-adherence to medication regimens and has therefore increased the rate of involuntary,
inpatient hospitalizations (Ohlsen, Peacock, & Smith, 2005). Therefore, it is important to monitor
glucose and lipid levels and provide support and encouragement to increase healthy diet and physical
activity to the SMI while they are treated with SGAs (Hultsjo & Hjelm, 2012).
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BARRIERS TO DIABETIC EDUCATION
A challenge with the current medical system in the United States is that the comorbidities of SMI
and type II diabetes mellitus are managed primarily in two different specialty clinical arenas: the
community mental health clinic and primary care clinics (Bennett & Manley, 1998; Happell, Scott,
Platania-Phung, & Nankivell, 2012; Hultsjo & Hjelm, 2012). The separation of services does not support
the argument of the importance of maintaining a healthy ‘mind-body’ connection in preventing illness,
nor in the value of holistic health. The debate over whether primary care or secondary care is responsible
for the physical health of people with SMI is common and occurs worldwide (Gray, Hardy, & Anderson,
2009).With this lack of connection in services comes a lack of coordination and follow-up. Chiverton,
Lindley, and Plum (2007) suggest that “all people with diabetes receive diabetes self-management
education” (p. 48). Educating patients with type II diabetes to self-manage their illness is a cornerstone to
successful diabetic care (Hultsjo & Hjelm, 2012; Mukadder & Beyazit, 2009) People with SMI face
numerous barriers to receiving quality care in primary care clinics such as staff’s intolerance for the
idiosyncrasies related to their psychiatric diagnosis and the shortage of allotted time for clinic visits. The
primary places the SMI seek health care are the community mental health clinics and emergency
departments (MacHaffie, 2002; Marion, Brauns, Anderson, McDevitt, Noyes, & Snyder, 2004). When
the SMI do pursue health care assistance from a primary care clinic, the literature indicates that the care
they do receive is sub-standard, 50% of the time they are not screened for hypertension and high lipid
scores (Hardy & Gray, 2010; Mesidor, Gidugu, Rogers, Kash-MacDonald, & Boardman, 2011; Nover,
2013).
In general, nurses tend to care for clients living with chronic illness in community settings more
than other medical professions. The mental health nurse tends to develop trust and rapport, instilling hope
in the SMI, more naturally than other health care professionals (Happell, Scott, Platania-Phung, &
Nankivell, 2012; Sutherland & Hayter, 2009; Svedberg, Jormfeldt, & Arvidsson, 2003). If health is the
balance between a ‘mind-body’ connection, and because mental health nurses at community health care
clinics are a primary contact point for the SMI, they may be in a better position and more skilled at
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BARRIERS TO DIABETIC EDUCATION
promoting healthy living and education among the SMI living with diabetes, so as to better equip them to
watch their diet, participate in physical activity in their daily life, and follow recommended dietary and
medication regimens to better manage their diabetes (MacHaffie, 2002; Miller & Martinez, 2003; Robson
& Gray, 2007 ). The question is, “why are mental health nurses, working in community mental health
centers, not taking on more of an active, professional role in screening, monitoring and educating SMI
clients for diabetes?” When nurses are licensed to do so, the SMI are at high risk for contracting type II
diabetes mellitus, and the SMI frequent community mental health centers for health care needs more than
primary care clinics.
The purpose of this paper is to discuss the barriers of the lack of (a) role clarity for mental health
nurses, (b) diabetic education in and screening tools for mental health nurses, and (c) administrative
support for the expansion of the mental health nurse role in educating clients living with the co-morbid
diagnoses of type II diabetes mellitus and SMI in the community mental health center setting.
Literature Search Tactics
The following search words were used in combination with each other: “nurse educator,” “nurse
coordinator,” “nurse manager,” “psychiatric health,” “psychiatric illness,” severe mental illness,”
“diabetes monitoring,” “diabetes education,” “primary care medicine,” “self-care,” “health promotion,”
and “schizophrenia,” in a systematic fashion in the following databases accessed through the Washington
State University’s on-line library website: Cochrane Library, PubMed, and CINAHL. One-hundred and
eighteen articles were identified and reviewed, 43 articles were selected. Several articles had overlapping
information applicable to the pertinent topics of this paper. The articles were then organized into the three
primary categories of barriers to why mental health nurses are not participating more in diabetes
monitoring and education of the SMI in the community mental health clinics: the lack of role clarity
within mental health nursing (35 articles), the lack of formal tools to guide mental health nurses in
monitoring diabetes in the SMI (17 articles), and the lack of administrative support in expanding the role
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BARRIERS TO DIABETIC EDUCATION
of the mental health nurse to include diabetes monitoring in the SMI (12 articles). The information was
synthesized and formulated into this review of the literature.
Theoretical Framework
Albert Bandura’s social-cognitive learning theory of self-efficacy provides the theoretical for this
paper. Self-efficacy is the construct through which expansion of the role of mental health nurse will be
considered. Transitioning mental health into becoming more knowledgeable about type II diabetes and
taking on a more active role in diabetic screening, monitoring, and educating SMI client in community
mental health clinics, will be examined. According to Bandura (1986b), the construct of self-efficacy is
“an expectation that one holds regarding one’s capabilities to accomplish a particular task or goal,” (as
cited in Walsh, 2008, p. 892). If an individual believes they can conquer obstacles, then they develop a
sense of personal agency. “ To be an agent is to intentionally make things happen by one’s actions….the
core features of agency enable people to play a part in their self-development, adaptation, and selfrenewal with changing times,” (Bandura, 2001, p. 2). In layman’s terms, self-efficacy can be considered
confidence in learning ability plus the drive and desire to attempt to build on prior knowledge and skill.
Self-Efficacy cannot be discussed without a particular task existing within the context of the
discussion (Walsh, 2008). Within this discussion, the particular task would be for the mental health nurse
to learn (or re-learn) how to properly screen and assess the SMI for signs and symptoms of diabetes
mellitus. Fortunately, mental health nurses in the United States are provided with a broad base of
education. In nursing school, they are taught about psychiatric nursing, as well as labor and delivery,
medical-surgical, public health nursing and points of interest in management as well. Clinical experiences
can range from clinic settings to the intensive care unit. The transition process of expecting mental health
nurses in community mental health clinics to take a more active role in diabetes screening, monitoring
and education care would cause stress among the nurses who are re-learning these skills, and possibly on
the systems within which they work. However, because of successes they are assumed to have
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experienced at some point in nursing school, or in a previous nursing position, it is anticipated that they
can access this sense of personal agency and absorb and then apply newly taught skills into their daily
practice.
Bandura (1977a) determined there exists an increased likelihood of adopting preferred behaviors
as the learner, if there are reinforcing influences. Research in educating and pedagogical processes
demonstrates that there are four primary sources of efficacy information: (a) students can gain efficacy
beliefs by directly experiencing the mastery of classroom tasks, (b) through a process of observational or
vicarious learning tasks which are successfully completed, (c) positive statements of persuasion from
others like teachers and parents often bolster self-efficacy, and (4) a sense of self-efficacy can be affected
by the learner’s physiological state (e.g.: increased heart rate, breathing rate, sweaty palms, etc.) (Walsh,
2008). Awareness of these primary sources of efficacy information is especially helpful when
administration begins planning for the expansion of the mental health nurse role. Teaching skills mental
health nurses need to know in small groups with clear, specific quizzes can reinforce their pre-existing
efficacy in nursing tasks. Teaching skills for diabetic prevention and monitoring in small groups will help
the nurses to observe their peers being successful in learning needed skills and tasks, and therefore their
sense of self-efficacy grows. Kind, supportive words of encouragement by management can also bolster
the sense of self-efficacy among the mental health nurses who will most likely be stressed and concerned
about their performance and ability to re-learn necessary skills correctly. Lastly, normalized feelings of
anxiety for the learner can assist them in attempting to mentally ‘override’ the distracting effects of
tachycardia, irritability and tachypnea which so often accompany the adult experience of trying to learn
what feels like foreign material. However, the most important aspect of the learner is their internal
experience of self-efficacy and their sense of personal agency. For these to be nurtured, implementation
of new training of mental health nurses in diabetic screening, monitoring, and education for the SMI
requires management to thoroughly understand the requirements of the newly expanded position.
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BARRIERS TO DIABETIC EDUCATION
Management must prepare and convey this to the nurses via thorough and clear communication and
planning (Walsh, 2008).
Literature Review
Lack of Role Clarity
Role Clarity. Psychiatric nurses have experienced drastic transitions in their role and job duties
since the 1960s. With the inception of deinstitutionalization, previous care given to the SMI, which was
considered custodial in nature, transitioned into that of a more rehabilitative role. The role of the mental
health nurse became that more of a social worker than of nurse, (e.g., assisting the client in finding food
and shelter), (Cres, Batal, Elasy, Casper, & Mehler, 1998; McCardle., Parahoo, & McKenna, 2007).
Psychiatric nurses struggled with the shift from custodial care to that of a more rehabilitative, communitybased paradigm. As one nurse stated, “You (as a mental health nurse) can’t do a proper job with the type
of patient we are getting these days. In the past you had the patient for years and you could train him
properly,” (Cowman, Farrelly, & Gilheany, 2001, p. 746). Although personality requirements of
flexibility and adaptability in conducting daily tasks as a mental health nurse are repeated themes within
the literature, and have assumed to have been a helpful requirement for becoming a nurse, there is a
pervasive lack of clear definition as to what is the role of a mental health nurse (Happell, Scott, PlataniaPhung, & Nankivell, 2012; Holm & Severinsson, 2012). This lack of clarity in definition has left mental
health nurses with a perceived lack of power and control, as well as role confusion (Cowman et al., 2001;
Nolan, 1993). Currently, studies which have attempted to define a clearer definition of the role of mental
health nurse, have spoken to its vagueness and have generated little supporting evidence for a valid
definition. Collegial criticism has created responses in the field of nursing such as the mental health nurse
is a “generalist with limited skills,” (Cowman et al., p. 747). Simply, there exists a lack of formal data to
speak to the clear definition of a mental health nurse’s role.
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BARRIERS TO DIABETIC EDUCATION
Cowman et al. (2001) performed a multi-methods qualitative study of 155 Irish nurses from
various specialties and grades of nursing rank in the Irish health care system, including mental health
nurses. Nine primary roles of mental health nurses emerged for analysis. The resulting data indicated that
mental health nurses have a central role among the SMI, and they collaborate well with other health care
professionals. One major role was to, “relate to managing patients and providing caring interactions, and
these activities appear to be fundamental to psychiatric nursing and central to mental health services,”
(Cowman et al., 2001, p. 752). The action and character of caring have been found essential to mental
health nursing. Cowman et al. (2001) also discovered that safety was a major theme of the role of mental
health nurse. Mental health nurses play “a major role in the management of crisis, including episodes of
violence. In mental health nursing, providing a stable and therapeutic environment is an important
attribute and nurses are particularly good at anticipating and managing situations of crises in clinical
environments,” (Cowman et al., 2001, p. 752).
Due to idiosyncrasies, i.e., psychosis, irritability and legal issues associated with the diagnosis of
SMI, many of our SMI lack family support, intimate relations, and advocacy from people who may assist
them with healthy living and seeking medical care when needed. It is for this reason that the role of the
mental health nurse is important in promoting mental and physical health and well-being of the SMI
(Adams, 2008; Hultsjo & Hjelm, 2012). The interpersonal dynamics which exist between the SMI client
and the mental health nurse are based on trust and the nurse’s use of self as a therapeutic tool (Adams,
2008; Hultsjo & Hjelm, 2012).It is because of this close-knit relationship and trust between nurse and
client, that mental health nurses are in the perfect position to provide diabetic screening, monitoring, and
education due to the frequency with which they interact with the SMI at community mental health clinics
(Blythe & White, 2012; Hultsjo & Hjelm, 2012). Happell, Scott, Nankivell, & Platania-Phung (2012)
found that mental health nurses interact with the SMI with more frequency than professionals at primary
care clinics. Barr (2000) found that clients with psychosis were more likely to be monitored by a nursecase manager at a community mental health clinic than any other health professional. Chiverton, Lindley,
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Tortoretti, & Plum (2007) stated mental health nurses have a “scope of practice and unique relationship
with clients (which) afford them the opportunity to make a difference in any setting or geographical
area,”( p. 48).
Nurse Attitude. Hardy and Thomas ( 2012) stated “nurses in particular were instrumental in
making immeasurable difference to how a person was able to experience health-care delivery, through
providing access and provision of adequate compassionate and dignified care”( p. 291). Svedberg,
Jormfeldt, & Arvidsson (2003) note “the mental health nurse must abandon the perspective of illness and
instead adopt the health promotion perspective” (p. 449). In other words, mental health nurses must
embrace an attitude of looking forward towards improving their client’s health, rather than tolerating their
current level of illness. This sentiment is not shared with all mental health nurses. According to Hardy
and Gray (2012), Australian mental health nurses have a “sense of pessimism about improving physical
health” (p.44) among the SMI. In the United Kingdom, it was the pervasive perspective of mental health
nurses that issues of physical health promotion and prevention were the tasks of primary care and that
“management of disease and modifiable risk factors would be an inappropriate use of their skills and
time”(p. 44). Pessimism is a pervasive attitude among mental health nurses (Robson & Gray, 2007).
Verhaeghe et al. (2011) found that mental health nurses felt more confident in assessing and educating the
SMI about mental health issues rather than any type of interaction surrounding the topics of physical
health and health promotion.
Jormfeldt, Svedberg, and Arvidsson (2003) conducted a phenomenographic study of 12 mental
health nurses working in a Swedish community mental health clinic. They found that nurses had vague
attitudes about how to most efficiently promote the physical health of the SMI, and were not applying the
general philosophy of nursing which is to strengthen the patient’s health. The participants’ attitude
towards promoting human growth, change and development within the SMI population was also dubious
at best (Jormfeldt, Svedberg, & Ardvisson, 2003).
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Howard and Gamble (2011) conducted a study of nurse attitudes surrounding mental health
nurses and how they see their responsibility in monitoring physical health of the SMI. Thirty-seven
mental health nurses were surveyed; 94% believed that discussing the physical health needs of the SMI
was imperative. Nurses also admitted feeling confident in their abilities to carry out such tasks.
Interestingly, only 5 of 55 physical health activities were recorded anywhere in the client charts. These
low levels of documentation indicate physical care of the SMI in this study was not a priority (Bradshaw
& Pedley, 2012).
In a descriptive qualitative study of 17 nurses Verhaeghe et al. (2013) found that mental health
nurses did believe that is was their role to strengthen their client’s ability to be more self-directed and
independent with their own health care. This group of participants also felt that discussions of health
promotion behaviors should only be engaged in if they were directly centered around topics of SMI as
indicated by the following comment: “Unless the unhealthy behavior is directly associated with the
mental disease, to my opinion, lifestyle (health) issues pertain to the private lives of our patients,”
(Verhaeghe et al., 2013, p. 1574). Conceptually, this a short-sided perspective that exists within the
profession of mental health nurses; for nurses to claim that they are practicing in a holistic manner and
then to minimize the importance of either the physical or mental realms of a client’s health, speaks to a
lack of knowledge regarding the complexities of the mind-body-spirit connection.
Mesidor et al. (2011) conducted a qualitative sub-study of 10 key informant interviews and
determined it was important “supportive staff that empowering individuals with (SMI) to attend to their
physical healthcare needs and to see value in improving their physical health status,” (p. 291). In order for
mental health nurses to be supportive educators and advocates for the SMI, and to promote health through
diabetic screening, monitoring, and education, vestment and interest in that role by the mental health
nurses must exist (MacHaffie, 2002). Regrettably, the literature indicates that mental health nurses do not
have the confidence in their ability to promotion healthy lifestyle choices such physical activity and
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healthy eating. Health promotion and educational programs should be integrated into the education and
professional development of mental health nurses (Verhaeghe et al., 2013).
Happell, Platania-Phung, and Scott (2013) conducted a cross-sectional study via email survey of
540 Australian mental health nurses. The investigators reported attitudes varied regarding further
education in physical health care of SMI patients. Sixty-five percent of participants believed that further
training in the physical health care of SMI would be of “significant value.” Almost one-third did not value
furthering their education. However, the survey results also indicated that mental health nurses were
“generally interested in further training in physical health care,” (p. 309).
Tasks to Learn and Implement. McDevitt (2004) wrote an article on the most current evidenced
found that mental health nurses are frequently the only source of contact for the SMI needing healthcare
assistance. Hence, it makes sense that the role of mental health nurse should include skill proficiency in
screening, monitoring, and educating this population for signs and symptoms of the co-morbid diagnoses
of Schizophrenia, as well as type II diabetes. McDevitt (2004) cites best practice interventions from The
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of
High Blood Pressure (JN7) as guidelines available to mental health nurses in screening and monitoring
the SMI in community mental health clinics. Mental health nurses could be responsible for drawing
HgbA1c levels, and intervening and referring for medication dose changes when A1c readings climb
towards 8% or a blood glucose average of greater than 170 mg/dl. Monitoring blood pressure readings
and referring for further assessment for pressures >130/>80, cholesterol low-density lipoprotein <100,
high density lipoproteins >40, and triglycerides >150 (McDevitt, 2004). Teaching patients to record in
blood glucose logs, and referring clients to care if readings are >130 before meals, are also interventions
mental health nurses could perform at community mental health clinics. Creating referrals for dilated eye
exams, collecting urinalysis to screen for nephropathy via microalbumin testing, foot exams using 5.07
monofilaments to rule out neuropathy, as well as administering annual influenza vaccines, are all ways
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BARRIERS TO DIABETIC EDUCATION
mental health nurses could provide diabetic screening and care for SMI with risk and or diagnosis of
diabetes mellitus (McDevitt, 2004).
Robson and Gray (2007) discovered through an extensive review of the literature that systematic
monitoring of diabetic risk factors at the onset of illness among the SMI can prevent complications from
diabetes. Mental health nurses have the opportunity to improve the mental and physical health of the
SMI. Essential monitoring includes (a) weight, (b) body mass index, including waste circumference, (c)
blood pressure , (d) lipid profiles, (e) screening for insulin resistance (e.g.: HgbA1c level, fasting blood
glucose as indicated, training the client to use a glucometer and log their results), (f) dental checks, (g)
eye checks, and (h) foot checks (Graber, Elasy, Quinn, Wolff, & Brown, 2002; Robson & Gray, 2007).
A review of the literature conducted by Hultsjo and Hjelm (2012) discovered that 8 of the studies which
were reviewed discussed key, educative themes all aimed at preventing type II diabetes among SMI.
Studies including education surrounding topics such as saturated fat content, smoking, various levels of
physical activity such as walking, jogging, and cycling, as well as the risks of smoking and substance
abuse.
Hultsjo and Hjelm (2012) conducted a qualitative, exploratory study of 10 mental health nurses
in a Swedish community mental health clinic. In depth interviews were conducted on the categories and
subcategories provided to prevent DM among the SMI. Results indicated that physical health monitoring
and promotion is the primary responsibility of mental health nurses working at community mental health
clinics. As addressed earlier with the learning process, mental health nurses will be more motivated to
engage in the role change of providing screening, monitoring and educating the SMI who live with
diabetes mellitus if they are appropriately guided to do so. Successful lifestyle changes among the SMI
are thought to be attributed to the relationship with their mental health nurses (Hultsjo & Hjelm, 2012).
Mental health nurse’s often know their clients the best and are trusted the most by the SMI clients they
serve. Therefore, they can act as conduit between the SMI and primary care clinics, if through their
monitoring and education, they believe the client would benefit from more intense medical treatment, not
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available at a secondary care site such as a community mental health clinic (Hultsjo & Hjelm, 2012). It is
due to this ‘gatekeeper’ position, that mental health nurses (and their clients) would benefit from them
having more knowledge and education, and playing a larger role in providing diabetes monitoring and
education to the SMI (Hardy, 2012).
Tosh, Clifton, and Bachner (2011) conducted a Cochrane review and found that randomized,
controlled trials do not exist in the literature which described ‘best practice’ guidelines for monitoring the
physical health of the SMI. Tosh et al. (2011) review article differentiates the necessity of physical health
promotion of clients with SMI, from the likelihood that the promotion will be effective in reducing
physical morbidity. Physical health monitoring does not need to be expensive. It can consist of tasks such
as measuring a weight, body mass index and waist circumference, blood pressure, screening for lipid,
thyroid, and glucose levels, as well as conducting a urinalysis, in addition to dental and eye checks. If
these are not implemented, ensuing costs in dollars and suffering will surpass the training costs and time
taken to educate mental health nurses at community mental health clinics in implementing more thorough
diabetes care of the SMI (Tosh et al., 2011). Blythe and White (2012) cited the information found in Tosh
et al. (2011) regarding the measurements of physical health as requirements for the SMI to have a
“soundness of body,” and stated that mental health nurses “should support and monitor the physical
health of people with SMI and facilitate swift access to primary care services should the need arise,” (p.
193). Coordinating medication adjustments and referrals to other needed specialists can all be executed by
a mental health nurse. The mental health nurse is a perfect candidate to augment and facilitate
appropriate, needed physical health promotion and prevention of diabetic complications, while supporting
necessary lifestyle change (Mueser, Bartels, Santos, & Pratt, 2012).
Miller and Martinez (2003) conducted a comparative descriptive design to measure staff
perceptions the importance of having nurse care managers involved in physical health screening and
assessment of the SMI. The setting of the study occurred in one of 30 different sites of a non-profit
community mental health clinic in a sprawling city in the United States and examined data from 7
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participants through pre- and post-intervention questionnaires. The results demonstrated that mental
health nurse case managers improve the quality of care the SMI are given at community mental health
clinics. The rate of current physical exams increased by 24% during the study which indicated that when
mental health nurses practiced a leading role in directing the physical health care of the SMI, routine
physical assessments were initiated and completed with increase d frequency. Nurses have the appropriate
education in the United States to screen and educate the SMI on topics of health promotion and wellness
(Miller and Martinez, 2003).
Bradshaw and Pedley (2012) conducted a review of the literature. Their research suggests that
mental health nurses could play a core role in screening and assessing signs and symptoms of diabetic
monitoring of the SMI at community mental health clinics. Monitoring can be accomplished through
easy-to-learn tasks such as referring the SMI for blood-work such as lipid levels, HgbA1c and monitoring
blood pressure. It was suggested by Usher, Foster and Park (2006) that mental health nurses must
document weight monthly, and conduct medication reviews and referrals as needed to a prescriber for
medication adjustments based on weight-gain risks (as cited in Bradshaw and Pedley, 2012).
Happell, Scott, Nankivell, and Platania-Phung (2012) conducted a qualitative, exploratory study
and collected data from six focus groups, each lasting one hour in duration. Data was gathered via semistructured interviews. A primary topic which arose from the focus groups was of the need for more
training of mental health nurses in health care topics. The educational preparation of the mental health
nurses influenced the degree to which they felt physical education of the SMI by the community mental
health clinic nurses is important. A generalist approach to nursing is not going to solve the issue of the
neglect of the physical health care needs of the SMI. An open discussion must occur of the importance of
creating different pathways in nursing education in order to prepare future mental health nurses for the
task of screening, monitoring and educating SMI clients with physical health needs (Happell et al., 2012).
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Lack of Diabetic Knowledge and Screening Tools
According to Robson and Gray’s (2007) review of the literature, there is no official consensus on
the best type of assessment too and frequency of physical assessment in SMI for diabetes symptoms, nor
on the monitoring of their condition. Guidelines exist which can direct practice of SMI clients with
diabetes, but nothing exists which is officially mandated. Additionally, poor knowledge and gaps in skills
among mental health nurses may contribute to the neglect of proper diabetic education and monitoring
among the SMI (Robson & Gray, 2007). Mental health nurses may feel additional tasks of diabetic
education and monitoring must be complex in order to be effective, but in actuality, especially with
regards to mental health nurses in the United States, these are simple tasks which need only be refreshed
within their pre-existing arsenal of professional knowledge (Robson & Gray, 2007). Robson and Gray
(2007) found that mental health nurses “demonstrated knowledge about nutrition and healthy lifestyles
was significantly improved following a single 30 minute education program for in-patients with
schizophrenia” ( p. 463 ). The importance of nurse educators in lowering HgbA1c levels among diabetic
patients has been studied and the literature suggests the addition of a knowledgeable, support nurse is an
imperative participant in diabetes education and treatment. Nurse education does lower HbA1c, blood
pressure, lipid profiles, and weight, while increasing physical activity, patient knowledge and selfmonitoring skills (Scain, Santos, Friedman, & Gross, 2007).
Nash (2009) conducted research using a 16-item self-report questionnaire with 138 mental health
nurses in the United Kingdom. The questions were centered on topics of education, the impact of diabetes
on their workload with the SMI, and the type of diabetes education care given. Results demonstrated that
mental health nurses were involved with a variety of care aspects around diabetes such as blood glucose
monitoring, nutritional advice, and communicating to diabetic nurse specialists. However, there were
major gaps in the diabetic care the mental health nurses provided the SMI. Information on diabetic
medication management, foot care, and referring patients to primary care were often neglected (Nash,
2009). Over half of the mental health nurses admitted to having no diabetic training in their career.
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Results of this study show care being given by mental health nurses was scattered and incomplete at best,
with no governing framework to guide them in practicing safely and competently (Nash, 2009; Wynn,
2011).).
Tranter, Irvine, and Collins (2012) conducted a review of the literature and found that there is no
clear guide to assist mental health nurses in monitoring the physical health of the SMI. They concluded
that topics of physical health assessment among the SMI lies within the “grey area of the literature,” (p.
1202). They point out that often there are many methodological issues in the studies which document
structured assessment tools for the mental health nurses and the SMI population. Issues such as high
dropout rates, small sample sizes, and lack of specific sample inclusion, minimize the validity of tools
found in the literature (Tranter, Irvine, and Collins, 2012).
Hemingway, Trotter, Stephenson, and Holdich (2013) created an interactive training package to
assist mental health nurses in learning how to better care for their SMI clients who were living with type
II diabetes. The training package was created by a collective group of professionals who work in both the
fields of diabetes and mental health nursing. The package consists of a written workbook, pre- and posttest, and DVDs related to relevant issues for diabetic care and the psychiatric needs of the SMI. As
mentioned earlier, any physical health monitoring skills the nurses did have may have been outdated
(Nash, 2009). Therefore, this program was designed to refresh the subjects’ knowledge base and skills
necessary to treat SMI clients with type II diabetes. The DVDs highlighted symptoms of diabetes and
medications used for its treatment. The learning package included case studies at the end of the program
to test and assess the mental health nurses newly acquired knowledge (Hemingway et al., 2013). Results
of this training package analysis indicated that the increase in mental health nurses’ knowledge of treating
diabetes among SMI was statistically significant (M=pre-score 4.76/ M= post-score 10.26; SD=2.05/1.05;
p<0.001). As Nash (2009) noted, mental health nurses were exposed to diabetes education in their
undergraduate education and were receptive to receiving more education to improve the care they give
SMI clients with co-morbid type II diabetes (Hemingway, Trotter, Stephenson, and Holdich, 2013).
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Hardy and Thomas (2012) conducted a review of the literature looking for themes in practice
implications for mental health nurses working in community mental health clinics with SMI clients and
co-morbid diabetes. They discovered that the United Kingdom’s Chief Nursing Officer’s review of
mental health nurses, recommended mental health nurses concentrate on increasing physical health care
provided to the SMI. In the United Kingdom, the National Institute for Health and Clinical Excellence
hosts 53 topics guiding mental health nurses towards toolkits and guidelines in managing co-morbid
diagnoses such as SMI and type II diabetes (Hardy and Thomas, 2012).
McDevitt (2004) authored an article based on the recommendations of the Seventh Report of
the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure suggestions for managing the physical health care needs of the SMI. Forms were created based
on suggested guidelines for diabetic screening and these can be implemented at mental health nurse
visits with the SMI to monitor variables of health (e.g.: blood pressure, lipid profiles, signs and symptoms
of diabetes, HbA1c and foot checks) among other screening issues (McDevitt, 2004). Internet websites
are listed at the bottom of the forms and can be used as reference tools for the mental health nurse in
augmenting the care provided to diabetic SMI clients. These website links are updated frequently and are
reliable sources of information for treatment (McDevitt, 2004).
Chiverton et al. (2007) created a nursing model of care geared toward 71 SMI adults with type II
diabetes. The program was called the Well Balanced Program. It was designed to be a 16-week intensive
nurse intervention study to increase the quality of diabetic care SMI clients received in an urban setting in
the United States. The University of Rochester, School of Nursing, in New York formed an alliance with
a local community mental health clinic. The nursing school designed the program based off of
recommendations of the American Diabetes Association (2007) and the following eight categories of
physical health were implemented by the mental health nurses involved in the study: (a) the intake, (b)
medications, (c) glucometer,(d) nutrition,(e) physical activity,(f) stress management, (g) skin, (h) foot and
eye care, through a screening. Clients were referred to community resources when needed. Seventy-four
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SMI clients actually completed the program. Health risk status, HbA1c and client satisfaction, were
evaluated. After the 16-week intervention, a statistically significant decrease was found in health risk
status (M=5, SD=17, P<0.001), and HbA1c levels were found to decrease as well (t=2.61, DF =70,
P<0.05). Client satisfaction was also found to have significantly increased (M=3.55, SD=0.44, P<0.001).
(Chiverton et al., 2007). Regrettably, after the study was completed, the majority of participants did not
maintain the behaviors of diabetes self-management they were taught during the study. This may speak to
importance of supportive education and weekly visits provided by educated, intervention-guided mental
health nurses (Chiverton et al., 2007). The Well-Being support program has been used as a structured
system in many locales.
Ohlsen, Peacock, and Smith (2005) set up the Well-Being Support program in community mental
health clinics across the United Kingdom. The research with this model was hoped to encourage the 95
persons with SMI into learning and practicing healthy lifestyle behaviors to alter outcomes of diabetes
mellitus, and other chronic health problems. Their primary goal was to screen and educate SMI clients to
decrease unhealthy behaviors within a brief number of structured client-to-mental health nurse visits. The
initial appointment screening measured blood pressure, pulse, weight, height, BMI, current medication
and medication history, familial demographics, and dietary assessment. A questionnaire on attitudes
towards medication and weight gain, neuroleptic rating scales, and a self-esteem scale were also
administered. Cigarette, alcohol and illicit drug use was assessed. Clients were taught how to use and
complete a food diary prior to their next appointment which was scheduled 2 weeks from the time of
initial intake. They were also offered participation in weight and physical activity groups which ran 1-3
times per week for the duration of the study. Results demonstrated that after only 2 educational
consultations, there was an improvement in quality of diet and an increase in self-esteem. Fifty-four
percent of overweight patients had lost weight during the program. Screening provided during the
intervention found that 37% of clients were hypertensive. Two percent were diagnosed with type II
diabetes mellitus during the intervention, above and beyond the 10% which were known to have diabetes
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mellitus (Ohlsen, Peacock, & Smith, 2011). The outcomes speak to the importance of proper screening
among the SMI for type II diabetes.
Phelan et al. (2004) developed a 30- minute tool called the Physical Health Check, designed to
assist mental health nurses and other professionals assess the physical health of the SMI. It contains 27
items, divided into four sections of screening: (a) diagnosis and medication regimen, (b) general health
and lifestyle, (c) symptom checklist, and then an (d) action plan to address concerns. The Physical Health
Check comes with a description of how to use the ‘brief tool’ and stresses that it should be utilized once
per year and accompanied by appropriate interventions (Phelan et al., 2004). In Phelan’s study, the
Physical Health Check was administered to an opportunistic-sample of six participants over the course of
six months. The Physical Health Check proved to be a useful tool during the six months of the study.
Mental health nurses found it to be useful in eliciting information from the subjects, their health history
and their health records, was easy to use, (and according to the mental health nurses), helped to spark
conversations at the community mental health clinic, regarding lifestyle practices among the SMI. Use of
the Physical Health Check became an intervention for beginning the discussion regarding health
behaviors which were not healthy and which were known to increase the chances of diabetes (e.g.: lack of
proper diet, lack of exercise, smoking) (Phelan et al., 2004). Fortunately, the Physical Health Check and
its guidelines are available on-line via a mental health charity based in the United Kingdom.
Hardy and Gray (2010) of the United Kingdom wrote an article regarding their promotion of an
assessment tool designed for use among SMI clients in community mental health clinics known as the
Health Improvement Profile. The Health Improvement Profile ensures that SMI clients received quality
physical health checks annually. The Health Improvement Profile was chosen as the preferred tool for risk
assessment. Its effectiveness in improving physical health is evidence-based (Hardy & Gray, 2010). The
Health Improvement Profile is a 27-item assessment, with versions for each gender. Completing the
Health Improvement Profile is approximately a 30-minute process. The tool was designed to assist mental
health nurses in determining points of health education and interventions when working with SMI clients
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in secondary care sites. Depending how the 27 items are scored, evidence-based interventions are
suggested. Mental health nurses in local community mental health clinics could use the Health
Improvement Profile to guide their screening, monitoring and education of type II diabetes in the SMI
population (Hardy & Gray, 2010). Training in the use of the Health Improvement Profile tool is available
and collected data can be coded and is easily collected. At the time this article was written, Health
Improvement Profile was not compatible with other computer charting programs, so data input would
need to be entered separately (Hardy & Gray, 2010). In the United States, mental and physical health
care are housed in separate buildings and systems. If a client with SMI can have a suicide risk assessment
every visit, what is hindering them from receiving a physical health risk assessment on a regular basis?
(Gray, Hardy, & Hoehn-Anderson, 2009). The Health Improvement Profile is a ‘star’ nurse-led model for
the mental health nurse to utilize in physical assessment of the SMI. The benefit for any organization in
using this model is not only a complete, easy-to-use format, but if purchase is supported and pursued by
administration, it comes with a 2-3 day training workshop for the mental health nurse (Happell et al.,
2012).
Hultsjo and Hjelm (2012) conducted a review of the literature and found that the transtheoretical
model of behavior change may be a helpful tool for assessing whether a patient is ready to implement
changes in their lifestyle choices. Six different stages are recognized in the ‘change process’: (a) precontemplation, (b) contemplation, (c) preparation, (d) action,(e) maintenance, and (f) relapse. By
identifying where the SMI client resides along this spectrum of change, the mental health nurse can tailor
their interventions and lessons on diabetes education and health management accordingly. This model,
used in conjunction with Motivational Interviewing techniques, can prove helpful when counseling
people who live with the co-morbid diagnoses of psychosis and type II diabetes (Hultsjo & Hjelm, 2012).
Wynn (2011) conducted a study with an intervention group of 20 mental health nurses working at
the Tuscaloosa VA Medical Center. The study involved exposing the mental health nurses to a Human
Patient Simulator for additional training in assessing and treating the SMI with co-morbid diagnoses such
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as diabetes mellitus. The results indicated that the mental health nurse’s clinical judgment skills improved
as they became more able to notice clinical signs of patient decompensation and struggle. Patient care
improved, and the need to transfer patients off the psychiatric unit decreased after the nurses were
exposed to the Human Patient Simulator training. Experiencing the improvement in their clinical skills
also inspired a portion of the mental health nurses to express a desire for more clinical training about
diabetes assessment, care and management (Wynn, 2011).
Lack of Administrative Support for Role Expansion
Explored earlier in this paper, is the sentiment among mental health nurses that diabetes and other
physical health problems are valued topics for some mental health nurses and not for others. Hultsjo and
Hjelm (2012) found through their qualitative, exploratory study of 12 mental health staff that a need
exists for mental health nurses to increase their knowledge of type II diabetes and the value which is
placed on healthy living and physical activity, among the SMI. As one subject responded to one of the
study’s interview questions:
“It’s very individual among us staff… if you think it is important, you work more with the
health issues. If not, well you maybe know in your profession. That it is important to exercise, but in a
way…what level… depends on your own interest” (Hultsjo & Hjelm, 2012, p. 484).
The attitude fostered in the community mental health clinic emanates from the individual mental
health nurse, but which component of an operational system such as a clinic is responsible for demanding
this positive attitude and promotion of diabetic knowledge and education? Administration is responsible
for mandating the expectations regarding the role of mental health nurse. It is also responsible producing
routes of communication between the community mental health clinic and off-site primary care clinics so
patient lab work and status can be interchangeable between providers at both facilities (Hultsjo & Hjelm,
2012).
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Holm and Severinsson (2012) found in their systematic review of the literature regarding the
barriers to facilitating, implementing and synthesizing the chronic care model in primary care, there were
significant deficits with administration in mandating role definition expansion. Their search yielded 4
primary studies which cited organizational leadership’s inability to develop a plan of change in their
institutions. Leadership experienced ‘professional pigheadedness’ from the providers which made
proposing change difficult. Some of the difficulty arose from organizational size; the larger the
organization, the more difficult it was to communicate required changes to every member (Holm &
Severinsson, 2012). Management must be the catalyst in any successful, organizational change through
supportive guidance (McHaffie, 2002; Najarian, Bartman, Kaszuba, & Lynch, 2013).
Mesidor, Gidugu, Rogers, Kash-McDonald, and Boardman (2011) conducted a qualitative substudy in a community mental health clinic. The intervention was adding a nurse practitioner into the
community mental health clinic in an effort to combine physical health assessment and care of the SMI
with psychiatric care. The most evident barriers included a deficit in administration’s drive to supply
financial resource and allowing for proper staffing so as to prevent burnout and overtaxed workers.
Administration’s neglect of increasing mental health nurse-to- client ratio, made it nearly impossible for
both the topics of diabetes and physical healthcare education, to be covered with the client in a thoroughly
effective manner (Mesidor et al., 2011).
Happell et al.( 2012) conducted an qualitative, exploratory approach in a sample of 38 mental
health nurses. The purpose of the study was to explore reasons for mental health nurses having such
diverse outlooks on the importance of learning and conducting diabetic screening, referral and treatment.
One primary issue they noted regarding administration was the frequent change in staff due to shortages,
inequitable allocations of financial resources, and funding priorities. Happell et al. (2012) also called for
an expansion of the role of mental health nurse to automatically include more education in screening,
monitoring, and in providing more frequent health assessments. Leadership would be responsible for
implementing these expected changes. They found there is a need for more education to be provided to
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mental health nurses. They also suggest that comprehensive education, like that offered in the United
States, does not necessarily produce skillful nurses in the areas of physical health care concerns, and the
insistence and provision for ongoing training has been lacks at best (Happell et al., 2012). Happell et al
(2013) stated “organizational commitment was identified as imperative, both in determining where the
responsibility for physical health care lies and for making and sustaining changes in practice in this area,”
( p. 215). It was identified that benefits of proper training of mental health nurses must be supported by
the organizational environment and professional training be made readily available (Happell et al., 2012).
Hardy and Thomas’ (2012) review of the literature addresses the importance of governmental
policy shifts in promoting improving physical standards of care for the SMI. The United Kingdom
undertook making these policy changes after realizing SMI clients at community mental health clinics
were not receiving equal physical health care screening and intervention as the rest of the population.
Mandatory competencies are in place for mental health nurses in the United Kingdom. Community
mental health in the United Kingdom now works closely with SMI clients through education and
monitoring to ensure proper management of diabetes and other chronic conditions, but this move forward
only occurred with the transformation and efforts of national level policy makers, such as their Chief
Nursing Officer and the United Kingdom’s National Service Framework for Mental Health (Hardy &
Thomas, 2012). The policy makers of the United Kingdom have made ‘no health without mental health’ a
priority and popular slogan, and have held quality mental health care in conjunction with quality physical
health care as a priority through their governmental policies (Hardy & Thomas, 2012). The physical wellbeing of the SMI is equally important to their mental health. This equal relationship will only be
maintained through clear, concise policy making and reassurance that our mental health nurses are
prepared to provide quality physical health care in the community mental health clinic setting (Bradshaw
& Pedley, 2012; Hardy & Thomas, 2012).
Verhaeghe et al.(2011) review of the literature found a lack of physical health assessment
expectations among institutions of higher learning in regards to which skills are being taught to nursing
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students. It was clear that nursing school leaders determine curriculum and lesson plans, and the depth of
the topic being taught, must do a more thorough job of teaching physical assessment and treatment among
their student who are bound for mental health. Institutes of secondary learning must begin developing a
more robust curriculum in health promotion (Verhaeghe et al., 2011). Administration has also
demonstrated an inability to provide adequate time for mental health nurses to perform tasks which are
required to prevent complications from diabetes, this lack of time was seen as a barrier to integrating
more of an educative role into the mental health nurse’s professional responsibilities (Verhaeghe et al.,
2013). Verhaeghe et al. (2013) concluded that governing bodies such as the European Psychiatric
Association have influence in establishing guidelines and standards of practice when the role of the
mental health nurse may need to be redefined. The association asserts that physical activity and a healthy
diet are the two primary interventions which mental health nurses can help teach the SMI in the
community mental health clinics. However, the lack of current knowledge is a significant barrier to
mental health nurses providing quality, holistic care to the SMI (Verhaeghe et al., 2013).
Druss, Von Esenwein, Compton, Zhao, & Leslie (2011) conducted a two-year follow-up chart
review study after 407 SMI participants were randomized into care-as-usual versus intervention of
intensive care via a registered nurse acting as the medical care manager. The participants in the
intervention group demonstrated improved quality of diabetic and cardiovascular care and preventative
screening and improvements in quality of life scales. The health improvement conclusions of this study
indicate that a well-trained mental health nurse, providing intensive diabetic screening, monitoring and
education at community mental health clinics can save money ($932 per client beginning in the second
year) from a health systems perspective. Regrettably, from a managerial cost perspective, the program
was not financially sustainable. Budgetary concerns is an important piece to discuss regarding the role of
administration in health care of the SMI and the discussions of valuing health, providing good care and
deciding how much profit is necessary to justify providing the care (Druss et al., 2011). If administration
and the financing bodies which govern health care reimbursement are always looking for a profit making
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design, they may not only be disappointment, but they may not fully understand the finer nuances of what
it means to live with SMI, nor might they understand the true meaning of provision of health care.
Employing extra personnel may cost more in the short term, but this expense may be offset by the longer
term financial savings in preventing co-morbid disease states such as diabetes in the SMI population
(Ohlsen, Peacock, & Smith, 2005).
Tranter, Irvine, and Collins (2012) conducted a review of the literature of assessment tools useful
for the mental health nurse in promoting diabetes and physical health screening and education, including
the Health Improvement Profile and the Physical Health Check. The authors noted that “policy makers
may be justified in championing physical health assessment and surveillance as a central tenet of service
provision” (p. 1211). In other words, clinic leaders in administration must insist and expect
systematically structured physical screening and assessment tools to be the backbone of accepted best
practice guidelines. The championing of these structured tools must be embraced at the clinic, state,
national and institutional levels of healthcare (Tranter, Irvine, &Collins, 2012).
Significance to Nursing
Identifying primary barriers that impede mental health nurses working in community mental
health clinics from providing quality diabetic screening, monitoring and education to SMI clients living
with diabetes is a complex issue. Valuing their role in addressing physical health issues is an important
place to begin. Training implementation of the mental health nurse by using a tool like the Health
Improvement Profile, or other skills training are important interventions. Efforts to push forward and
blend mental health care and physical health care in secondary care clinics must begin with management.
Management must clarify role expectations for the nurses they employ, provide proper screening tools
and support diabetic education, both in spirit and financially.
A successful diabetes regimen is patient driven. Individuals living with SMI and the challenges of
a motivation, poverty often lack family support. Mental health nurses at the community mental health
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clinic may be the most influential and valuable relationship they encounter (El-Mallakh, 2006). Mental
health nurses must be willing to embrace the blended education they initially received, and build on their
knowledge of physical health issues affecting the SMI. Flexibility in the changing world of medical
reimbursement will prove to be more financially efficient and of higher quality if SMI clients can be
treated for their diabetes at the community mental health clinic.
Recommendations for Future Research
Research on the role of mental health nurses in performing screening, monitoring, and education
for type II diabetes among people living with SMI has substantially increased, primarily in the last 10
years. The literature is lacking randomized control trials that are concealed to group assignment. Studies
can focus on testing effective methods for lowering type II diabetes rates among persons with SMI
receiving care in mental health clinics. More research is needed on the effectiveness of mental health
nurse-led interventions in decreasing HgbA1c levels, interventions on screening for lipid levels,
hypertension, and foot care.
Client satisfaction measures regarding the experience of the SMI client after mental health nurses
provide diabetic screening and support would provide valuable insight into the expanded role definition of
mental health nurses. Group education among diabetic clients was a common theme in the literature.
Testing the benefits of individual versus group education could benefit administrators when considering
staff allocations. More research is needed to study improvements in diabetes self-care among SMI clients
at the community mental health clinic. Digital reminders (eg: emails, text messages from nursing staff)
improve adherence to self-care among persons with diabetes was another common theme addressed in the
literature as was Cognitive-Behavioral therapy use among the SMI population. A future study combining
CBT techniques, group education, and nurse lead screening, monitoring, and education, with
accompanying measures in quality of life among the SMI being treated at secondary care facilities, would
be a fascinating project for a doctoral student.
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Lastly, communication between community mental health clinics and primary care clinics must
improve in order for SMI to receive standardized care in both settings. Designing a study which analyzes
the flow of information between mental health nurse and primary care clinic could produce results which
can help dissolve boundaries between the two spheres of health. By smoothing the flow of information,
and building a relationship between the community mental health clinic and the mental health nurse, care
of the SMI and monitoring of their DM and other chronic conditions can be smoother, and provide the
client with valuable care and higher quality of life.
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