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Table 1 Mental health nurses and physical healthcare (knowledge, experience, attitudes, education) Included studies

From: Mental health nurses’ attitudes, experience, and knowledge regarding routine physical healthcare: systematic, integrative review of studies involving 7,549 nurses working in mental health settings

Study and [data collection year] Location Study design and focus Data sources/ outcomes/ analysis Sample Intervention/ Exposure Level of analysis Main findings
MHNs and physical healthcare: Cross-sectional and qualitative studies
Bressington et al. [19] [2016–17] Qatar, Hong Kong, Japan Cross-sectional survey. Physical healthcare. Questionnaire: PHASe [11] and Japanese translation N = 481 MHNs (39% response rate) 57% F; < 5-yrs in MH 14%. Routine practice National/ Inter-national Nurses’ attitudes and confidence predict physical health management participation. Training needs perceived across registration and nationality; especially cardio-metabolic health.
Brimblecombe et al. [53] [2005] England Mixed. Cross-sectional, qualitative. Physical healthcare. Purpose-designed tool. Content analysis. Researcher categorisation and inferential statistics. N = 326 submissions from Higher Education(HE) and care organisations, open meetings, individual and MHN groups (n = 119) Consultation document National Promoting healthy lifestyle most commonly mentioned by HE organisations. ‘Physical assessment skills’ were required according to open meetings and NHS organisation respondents but significantly less so by individual or groups of MHNs.
Ҫelik Ince et al. [56] [2017] Turkey Qualitative. Physical healthcare. Semi-structured interviews on physical health care N = 12 mental health nurses Routine practice Two hospitals Themes: 1. Barriers to physical healthcare; 2. Current physical healthcare practices; 3. Motivators for providing physical healthcare; 4. Needs if physical health care is to improve.
Chee et al. [41] [2015] Australia Cross sectional survey. Physical healthcare in First Episode Psychosis care Questionnaire: Amended PHASe [11] N = 207 MHNs and Generalist nurses working in mental health services Routine practice National Varying levels of physical health practice. See Table 2
Clancy et al. [40] [not reported] Australia Cross sectional survey. Physical healthcare. Questionnaire: Adapted PHASe [11]; (Happell et al. [30]. Additional items. N = 385 clinicians and managers (n = 198 nurses 51.4% on a 31% response discipline- rate) Routine practice Service MHNs rated as having strong role legitimacy (monitoring, motivating, supporting) in relation to physical health interventions, medication effects, substance use, and sexual health both in absolute terms and relative to most other disciplines.
Delaney et al. [54] [not reported] US Cross-sectional survey. Physical healthcare. Questionnaire. Researcher categorisation of responses and descriptive statistics. N = 1899 Advanced Practice MHNs Routine practice National Respondents rarely identify physical assessment (< 4.0%) or pathophysiology (0.5–5.0%) skills as a deficit.
Ganiah et al. [42] [not reported] Jordan Cross-sectional survey. Physical healthcare. Questionnaire: PHASe [11]. Arabic translation. N = 225 MHNs; 40.9% F; M experience 6.7-yrs Routine practice National Significant but small correlations between participants’ attitudes and: reported physical healthcare practice (r = 0 .39); years in mental health care (r = − 0.207); M n assigned patients per nurse (r = − 0.18)a
Happell et al. [30] [2012] Australia Cross-sectional survey. Physical healthcare. Questionnaire: Modified PHASe [11] N = 643 see 5. Routine practice National Varying levels of physical health practice and attitudes. See Table 3.
Happell et al. [31] [2012] Australia Cross-sectional survey. Physical healthcare. Questionnaire: Strategies for Improving Physical Health of Consumers with Serious Mental Illness. Adapted PHASe [11] N = 643 MHNs (22% response); 72.7% F; < 10-yrs in MH 15.7% Routine practice National Training priorities: cardiovascular health (76.2%); diabetes (71.4%); assessment of physical illness (69.2%); weight management interventions (68.6%); exercise (66.4%); healthy eating (64.2%); smoking cessation (63.0%); reproductive health (62.4%); sensitive health issues (62.1%).
Happell et al. [32] [2012] Australia Cross-sectional survey. Physical healthcare. Questionnaire: Rate strategies for improving patients’ physical health N = 643 see 5. Routine practice National High endorsement of nurse-based strategies (lifestyle programmes, screening), less for reducing antipsychotics. Most value attached to colocation of mental and physical health services, training GPs.
Happell et al. [72] [2012] Australia Qualitative. Physical healthcare. Focus groups: What training needed to address physical health of patients? N = 38 MHNs; MH experience < 1 to 22-yrs (Mdn = 11-yrs) Routine practice Region Training priorities: physical health care: physical assessment, physical observations, diabetes. Strong beliefs about modes of training, access to training, and organizational commitment.
Happell et al. [73] [2012] Australia Qualitative. Physical healthcare. Focus groups. Topics: Physical illness: physical health of patients; care responsibility; patient engagement N = 38; MH experience < 1 to 22-yrs (Mdn = 11-yrs) Routine practice Region Common experience of comorbid physical/mental illness in clients. Important for health-care services to treat and prevent physical illness. Divergent views on nurses’ capacity to contribute to better outcomes.
Study and data collection year Location Study design and focus Data sources/ outcomes Sample Intervention/ Exposure Level of analysis Main findings
Happell et al. [33] [2012] Australia Cross-sectional survey. Physical healthcare. Nurse Collaboration With Other Staff on the Physical Health of Consumers questionnaire N = 643 see 5. Routine practice National Physical health most frequently discussed with GPs, psychiatrists, case managers (Mdn = ‘Often’); least with OTs and SWs (Mdn = ‘Never’). Nurses who discuss physical health with one other profession are more likely to discuss it with a second type (true for 52/56 possible (range r = 0.21 to 0.59 a).
Happell et al. [34] [2012] Australia Cross-sectional survey. Physical healthcare. Adapted PHASe [11] plus new items. N = 643 see 5. Routine practice National Physical health care was explained by self-reported nurse views on patient health, rights and nurse role ideal (‘nurses should be involved in physical health care’), and organisational factors. The latter may be more important in determining physical health care
Happell et al. [35] [2012] Australia Cross-sectional survey. Physical healthcare. Questionnaire domains: 1.Perceived Relative Health; 2. Healthcare Arrange-ments; 3. Value of Physical Healthcare Initiatives; 4. Cardio-metabolic Health Nurse (CHN) support N = 643 see 5. Routine practice National Predictors of CHN support: belief in GP physical healthcare neglect, interest in training; higher perceived value of improving physical health care (standardized β coefficients 0.11. 0.14, and 0.27 respectively)b
Howard & Gamble [45] [not reported] UK Cross-sectional survey. Physical healthcare. Purpose-designed self-report questionnaire N = 37 ward-based MHNs (47% response); Qualified < 5-yrs 43% Routine practice. Service Gap between perceived responsibility and practice highlighting need for role clarification and skills training
Mwebe [55] [not reported] UK Qualitative. Physical healthcare. Semi-structured interviews on physical health monitoring N = 11 MHNs; < 10-yrs length of service 72.7% Routine practice. Service Commitment to physical health screening and monitoring role. Themes: current practice; perceived barriers; educational needs; strategies to improve
Nash [71] [not reported] UK Cross sectional survey. Physical healthcare. Purpose designed self-report questionnaire N = 179 MHNs (53% response); M-yrs qual-ification 3.5, < 10-yrs 58% Routine practice Service 58% experienced in physical health care giving; 55% received training; 71% currently providing physical care: diabetes (53%), cardiac (23%), chest (19%), skin (32%), analgesia (32%), detox (13%). Training needs: 96% willing to attend skills training.
Osborne et al. [47] [not reported] Australia Cross-sectional survey. Physical assessment skills Physical Assessment Skills Inventory [74, 75] Barriers to Registered Nurses’ Use of Physical Assessment Scale [76] N = 433 registered nurses including 34 (7.8%) mental health nurses; 90.8% F; <  3-years experience as RN 10.8%. Routine practice Hospital Mental health nurses use fewer (7/21) ‘core’ physical assessment skills (those used on average every day) than nurses in other specialties (surgical; maternity; medical; oncology; mean = 10.2). The skills most regularly used by mental health nurses (measuring temperature 73.5%, measuring SpO2,76.4%, measuring blood pressure 70.6%) are less commonly used than by all other nurses ((85.6, 85.4, and 75.4% respectively).
Phelan [77] [not reported] UK Audit. Physical healthcare. Physical health care (PHC) check tool 60 community-based clients. PHC completed by MHNs (68.3%) Routine practice Team More problems in this group of patients than in an audit of records from a similar team not using PHC. Tool seems to help nurses identify problems.
Robson & Haddad [11] [2006–7] UK Cross-sectional survey. Physical healthcare. Questionnaire: PHASe N = 585 MHNs; 62.2% F Routine practice Region Varying levels of physical health practice and attitudes. See Tables 2 and 3.
Robson et al. [20] [2006–7] UK Cross-sectional survey. Physical healthcare. Questionnaire: PHASe [11] N = 585 MHNs see 10 Routine practice Region Varying levels of physical health practice and attitudes See Tables 2 and 3
Shuel et al. [78] [2007–8] UK Audit/ Survey Physical healthcare. Serious Mental Health Improvement Profile (HIP), short semi-structured interviews N = 31 patients seen by two HIP-trained MHNs Use of HIP in routine practice Service The HIP used by MHNs identifies some physical issues. Authors recommend that training is required if they are to use it effectively.
Wynaden et al. [44] [2014] Australia Cross-sectional survey. Physical healthcare. Questionnaire: PHASe N = 170 nurses in public mental health services Routine practice Three services Workplace culture influences the physical health care provided. Nurses are uncertain about where there priorities lie.
Study and data collection year Location Study design and focus Data sources/ outcomes Sample Intervention/ Exposure Level of analysis Main findings
MHNs and physical healthcare: Longitudinal/Intervention studies
Fernando et al. [66] [not reported] UK Longitudinal AB. Physical healthcare. Purpose designed questionnaire N = 63 nurses and junior doctors (15[24%] MHNs) Physical/ mental health simulation Region Total knowledge, attitudes, and confidence scores improved but no data specific to delirium.
Haddad et al. [43] [not reported] UK Longitudinal AB. Physical healthcare. Questionnaire: PHASe [11] N = 49 (response 60%); < 10 years since qualification 60%. Low secure mental health unit. Patient personal health plan Workshop. Service Modest (d = .09) statistically-significant improvement in staff knowledge scores and attitudes to involvement in physical health care. See Tables 2 and 3
Hemingway et al. [68] [not reported] UK Longitudinal AB. Physical healthcare. Multiple choice format knowledge questionnaire N = 204 (n = 89 registered and 115 students). Mdn age 39-yrs 5 × 1-d physical healthcare workshops Region All knowledge areas significantly improved from A to B. Effect sizes d = 1.4 wound care to 4.6 diabetes via 1.7 Oral health, 2.79 IM injections and 2.74 HIP). Almost all participants satisfied or very satisfiedc
Terry & Cutter [46] [not reported] UK Longitudinal AB plus qualitative. Physical healthcare. Purpose-designed self-report questionnaire [45] 15 MHNs in AB study, 5 in focus group; < 3-yrs in post 23.1% Physical care degree module Module cohort. M confidence 97.9 T1 to 121.1 T2, p < .001 r = 0.98. Improvements on 25/39 questionnaire items. Focus groups: physical healthcare becoming more important in practice. Lack info and want more knowledge. a
White et al. [67] [not reported] UK Longitudinal AB. Physical health. Knowledge of/attitudes to (10 MCQs) physical health in severe mental illness N = 38 matched pairs 78.3% F; < 5-yrs in health care 47.9% 2.5 h physical health work-shop. HIP Region Statistically significant knowledge-gain post-workshop (d = 1.16). Participants satisfied with content and willing to apply learningc
MHNs and care for specific physical health issues: Cross-sectional and qualitative studies
Artzi-Medvdik et al. [48] [2006] Israel Cross-sectional survey. Breastfeeding in women with schizophrenia diagnosis. Knowledge and attitudes to breastfeeding [79]. Adapted Attribution Questionnaire-27 [80] N = 110 (response 57.9%) F RNs practicing in psychiatry/obstetrics (MHN n = 37; M yrs. registered 6.64]; Midwifery n = 40; postpartum care n = 33). Routine practice MHNs vs. Midwives vs. Post-partum care Positive attitudes to breastfeeding in mothers with schizophrenia in 70% of respondents and to women with schizophrenia. MHNs significantly less knowledge re: breastfeeding, poorer attitudes to breastfeeding, more knowledge about schizophrenia. Predictors of positive attitude towards breastfeeding in women with schizophrenia: academic education (OR = 2.87), fear of schizophrenic patient (OR 0.27), extended schizophrenia-related knowledge (OR = 0.35)d
Dorsay & Forchuk [59] [not reported] Canada Cross-sectional survey. Sexual health Purpose-designed survey questionnaire N = 66 MHNs (response 20%) Routine practice. Service Participants knowledgeable and competent. Most common sexual issues were abuse, contraception, STDs. Patient interviews suggested most had not been appropriately engaged in conversation.
Happell & Platania-Phung [35] [2012] Australia Cross-sectional survey. Cardio-vascular health promotion Adapted PHASe [11] plus new items. N = 643 see 5. Routine practice National Perceived patient–nurse collaboration as a dual-determinant of nurse perceived barriers and self-reported health promotion to patients with SMI. Perceived barriers to consumer lifestyle change did not predict health promotion. The effects of nurse–patient collaboration were significant, but small.
Happell et al. [36] [2012] Australia Cross-sectional survey. Cardio-metabolic Health Nurse Role 133 open comments about the role of the CHN N = 643 see 5. Routine practice National Nurses see the specialist role as suitable and valuable for mental health services. Some concerns about role fragmentation with increasing specialty.
Happell et al. [38] [2012] Australia Cross-sectional survey. Dental health. Adapted PHASe [11] plus new items. N = 643 see 5. Routine practice National The majority of nurses considered the oral and dental conditions of people with serious mental illness to be worse than the wider community. When compared with a range of significant physical health issues (e.g. cardiovascular disease)
Hughes & Gray [63] [not reported] UK Cross-sectional survey. HIV/AIDS Purpose-designed questionnaire 283 Mental health workers (44% response). 51% nurses Routine practice Region Sexual health promotion: part of role (80.3%); mandatory training required (78.3%); comfortable with LGBT issues (71.3%). People with SMI should be discouraged from having sex (1.8%); Discussing sexual activity encourages it (4.3%); ok to test HIV status without patient consent (4.6%).
Johannessen et al. [62] [not reported] Norway Qualitative. Omega-3/ Nutrition. Questionnaires (students) and interviews n = 50 student nurses; n = 20 tutor nurses; n = 5 psychiatrists. Routine practice Region Nutrition considered important but few evaluations are made. Lack of Omega-3 knowledge. Unclear divisions of responsibility.
Klein & Graves [39] [2014] US/ Canada Cross-sectional survey. Mild brain injury (MBI). Online survey questionnaire N = 1049 nurse practitioners (23% response) inc. 139 MHNPs (84.3% F; < 5-yr as NP 25.4%) Video of standardised MBI patient National/ cross-border MHN practitioners significantly less likely to: have had relevant training, think the injury is a concussion, use standardized instruments. Reported discomfort with the survey as due to knowledge deficit. Less likely to have had relevant training.
Study and data collection year Location Study design and focus Data sources/ outcomes Sample Intervention/ Exposure Level of analysis Main findings
Magor-Blatch & Rugendyke [50] [not reported] Australia Cross-sectional survey. Smoking. Attitudes toward Smoking Scale [81] Shore et al N = 98 Mental Health Practitioners (n = 9 nurses) all settings Routine practice. Region 44.9% approved smoke-free policy. Attitudes to smoking restrictions (r = 0.35), concerns re: second hand smoke (r = 0.37), and to relationships with smokers (r = .39) associated with smoke-free agreement. Only attitudes pro- (positive relationship), and anti- the smoking ban (negative relationship) predicted ban supporta
Nash [82] [not reported] UK Cross-sectional surveyDiabetes 16-item questionnaire N = 138 MHNs (response 63%); qualified< 3-yrs 26%; Routine practice Service 69% currently providing diabetes care (most daily or weekly or bi-weekly 65%) Need for training in all aspects of diabetes care. 64% had not received training, 86% required further training.
Parel et al. [65] [Not stated] India Cross-sectional survey. Smoking. Purpose-designed survey questionnaire. N = 45 nurses in a psychiatric department. Routine practice Department Moderate or greater knowledge about tobacco smoking and smoking cessation among participants. Cessation-training and attitudes to cessation negatively associated.
Quinn et al. [83] [not reported] Australia Qualitative. Sexual health In-depth 1:1 interviews about experience of discussing sexuality with patients. 14 MHNs; 57% F; MHN experience 2–39 yrs. (M = 14.9) Routine practice. Service Common reference to: sexual function assessment, psychotropic side-effects, patient embarrassment, and pros and cons of information. Sexual side effects recognised as impacting on medication adherence but most did not discuss it with patients.
Quinn et al. [60] [Not stated] Uk & Australia Cross-sectional survey. Sexual health care/ Purpose-designed survey questionnaire. Amended from Hughes and Gray [63] N = 303 (n = 219 and 84 from Australia and UK respectively) Routine practice International The results demonstrated that mental health nurses do not routinely include sexual health in their practice and are poorly prepared in knowing what to do with a sexual health issue, and what services to assist patients to use.
Sharma et al. [64] [not reported] Australia Cross-sectional survey. Smoking. Online national survey questionnaire based on Ford et al. [84] N = 267 mental health clinicians (22.8% nurses) Routine practice National Compared with a reference category of medical practitioners, nurses were only significantly less likely to arrange follow up of smoking cessation interventions but not to ask, assess, advise, or assist. Training in smoking cessation associated with more cessation-related helping behaviour. Most believe harm reduction approaches to smoking cessation are effective.
Sharp et al. [58] [not reported] US Cross-sectional survey. Smoking. Questions assessing intervention skills followed Ask–Advise–Assess–Assist–Arrange recommendations [85] N = 1381 MHNs (approx. 33% response); < 5-yrs experience in MHN 17.2% Routine practice National Most nurses assessed patients for smoking; fewer advised against smoking, referred for cessation, or delivered cessation interventions. More knowledgeable/self-efficacious nurses referred patients to smoking cessation resources (d = 0.41 to 0.8) or provided intensive interventions (d = 0.45 to 0.73); those with cessation- consistent beliefs more likely to refer (d = 0.48 to 0.49) or provide intervention (d = 0.49–0.90)c
Verhaege et al. [61] [not reported] Belgium Qualitative. Health promotion. Focus groups (staff) interviews (patients) N = 17 MHNs; N = 15 patients homeless service Routine practice Service Benefits of physical and mental health identified, but barriers to integrating healthy lifestyles into patients’ lives: lack of time and personal views and attitudes towards health promotion were important.
MHNs and care for specific physical health issues: Longitudinal/intervention studies
Happell et al. [36] [not reported] Australia Longitudinal AB survey. Cardio-metabolic health. 14-item questionnaire N = 42 nurses initially and N = 21 at follow-up. Introduction of a CHN Service Nurses initially supportive of the role. 6-month trial of a CHN reduced ambivalence. Only one of 14 items statistically significant A CHN would help prevent onset of cardio-metabolic disorders in patientss; greater proportion gave a negative response at post-intervention (d = 0.59)c
Hemingway et al. [70] UK Longitudinal AB. Diabetes MCQ 12 items. Course evaluation questionnaire. 26 student nurses and 9 qualified staff. See 36   M improvement d = 1.37. Both students and qualified improved equally. Course evaluated well. c
Hemingway et al. [69] [not reported] UK Longitudinal AB plus qualitative element. Diabetes Custom MCQ 13 items; 10-item evaluation questionnaire. Content analysis of open ended questions. N = 48 (22 students, 26 qualified) DVD, present-ations, skills sessions. Region M (SD) Pre- 5.9(2.17) Post 7.04(1.85), p < 0.01 (d = 0.56) Course evaluated highly. Themes: Satisfaction; Suggestions to improve; Use of a life story; Clinical perspective.
Study and data collection year Location Study design and focus Data sources/ outcomes Sample Intervention Level of analysis Main findings
Hunter et al. [49] UK Mixed. Longitudinal AB. Qualitative. Obesity. Nurses Attitudes towards Obesity and Obese Patients Scale [86]. Focus groups. 39/205 eligible participated pre-test and 29/39 completed both Pre- and post-) Simulation ‘bariatric empathy suits’. Student cohort NATOOPS α acceptable overall. Factor 5 0.541/0.414 at pre−/post. Pre- post differences on F1 F2 and F5. No differences on between group attitudes. Qualitative themes: Physical impact of the suit; psychosocial impact of the suit; thinking differently; simulation as learning experience; challenges and recommendations.
Sung et al. [51] [not reported] Taiwan Stage 1: Qualitative. Stage 2: RCT. Sexual health. 1.Focus Group; 2. Knowledge of sexual healthcare scale; Attitude toward sexual healthcare scale. Self-efficacy for sexual healthcare scale: Stage 1: 16 nurses, M clinical experience 15.9-yrs, 100% F. Stage 2: N = 117 59 Experimental 58 Control. n MHNs unclear: allocation stratified to ensure representation. Stage 1: None. Stage 2: Sexual healthcare training 16-h over 4-weeks. Service Stage 1: themes: a) Views and experience in dealing with sexual healthcare b) Expectations re: training. Stage 2: Experimental group significant improvements in knowledge (d = 1.02), attitude (d = 0.67), and self-efficacy (d = 1.02). Relative to controls, they made significantly greater knowledge improvements (β = − 0.12, p < 0.01) and attitudes (β = − 0.25, p < 0.05), but not self-efficacy (β = − 0.33, p = 0.18). No psychiatric versus other ward-type effectb,c
Wynn [52] [not reported] US Longitudinal ABDiabetes. Clinical judgment rubric [87]. Diabetes-related medical transfer. N = 20 MHNs in veterans mental health hospital Simulations re diabetes care. Service Statistically significant pre post improvement scores on clinical judgment (d = 4.8). Proportion of medical emergency reports involving diabetes fell from 55 to 20% in post-intervention month.
  1. aPearson’s r Small = 0.3, Moderate = 0.5, Large = 0.7; bStandardised β coefficient outcome variable rises by stated amount for each 1 SD unit change in the predictor variable; cd = Cohen’s d 0.2 Small 0.5 Medium 0.8 Large effect size dOR Odds Ratio relative risk of the predictor variable with the reference variable e.g. extended knowledge associated with positive attitudes OR 0.35 means a person with extended knowledge is only 35% as likely to have positive attitudes than someone without extended knowledge