Physical health care in mental health settings: how a knowledge exchange can shed light on opportunities for policy, practice, education and research improvement

Dr Seren Roberts

People with severe mental illness experience poorer physical health than the general population, with 13–30 years shortened life expectancy. This health inequality is well known. Many health policies world-wide are seeking to close this health gap. Health promotion and improving access to health services has been a priority for achieving improved health outcomes for this disadvantaged population.

A less researched area is about the role of mental health nurses in monitoring physical health and providing physical health care across all mental health services.  Yet mental health nurses can play a critical role in this area. What we know from existing literature is that mental health nurses:

• Report varying levels of physical health practice, with positive attitudes and willingness in some areas of health (dietary and exercise advice) but less so in others (cancer screening and smoking cessation).
• Are not routinely supported by physical health care education and training.
• Hold divergent views on nurses’ capacity to contribute to better health-care processes.
• Believe that health promotion should permeate the entire organization of mental health care and that shared responsibility for health and health promotion activities should exist at all levels.
• Recognise the importance of monitoring and screening of physical health needs butthis  needs investment and time to build expertise and confidence through education, training and skills development.
• Are divided and uncertain where their responsibilities lie.

Recommendations for mental health nurses have been suggested based on a UK study of mental health nurses’ attitudes, and wider literature not pertaining to mental health nursing; however, little research has been published that clearly shows what mental health nurses can do in their practice. Importantly, specialty preparation for mental health nurses in the UK differs from many other countries including the USA, New Zealand and Australia, where all graduate nurses are prepared through generic or comprehensive educational programmes. This provides an opportunity to explore and understand the advantages or disadvantages of these educational differences in preparing nurses for monitoring physical health of people with mental health conditions, and how these play out in practice. We sought a knowledge exchange to initiate work in this area through first hand observations.

Through a partnership with the Mid North Coast Local Health District (MNCLHD), New South Wales, our objectives were to: a) learn from each other; b) gain a mutual understanding of mental health care in respective countries; c) build relationships for collaboration and advancing research, d) identify opportunities to grow evidence to further enhance the utility of technology to enhance nursing care in mental health settings.

To this end, a two-way knowledge exchange was arranged through two intensive 3-4 week placements; one being in Cardiff, Wales, UK (March 2023) and the other in Coff’s Harbour, New South Wales, Australia (September 2023). These reciprocal placements involved visiting a range of mental health settings to observe, initiate discussions and share experiences. The placement also provided opportunities to engage with relevant research institutes and policy makers.

Observing real life care in real time allowed partners to pick up subtleties and nuances in practice that may otherwise not be well known or published, but nevertheless have a significant part to play in the patient experience of healthcare and possible outcomes. These observational opportunities allowed reflection on the cultural and educational context, and how these play a part in the evolution of mental health environments, practices and education.

Through the knowledge exchange process, we learned that there was a real appetite and interest in learning from other health systems both strategically and operationally. Nurses on the coal face through to policy makers were keen to engage with the learning opportunity. Real time immersion in the operational contexts of other countries can also enhance the translation of evidence to practice. Sharing clinical alternatives, challenging assumptions, and discussing varying approaches to physical health care enabled acceleration of the pace of change. Some discussions during the knowledge exchange placements led to direct and immediate changes to practice to enhance care. We also recognised that the knowledge exchange provided space for conversations to support intentional reflection on clinical practice to help trigger rapid reform for innovation in mental health care.

We identified key benefits of the knowledge exchange process, which are:

• Mutual and collaborative understanding of the problem area;
• Acceleration of joint learning and information sharing;
• Identification of cross-cutting solutions to longstanding challenges;
• Having space and time to enable challenging conversations that hinged on moral, ethical and legal discourse around physical health care and the role of the mental health nurse in this;
• Seeding opportunities for cross pollination of ideas relating to wider mental health nursing issues and practices, as well as the role of the educational context in these; and,
• International collaboration to advance mental health nursing research.

While we can learn a great deal from research, and wider published work, about models and approaches to care, and indeed the role of the nurse, but until we see firsthand mental health nursing care in action in different cultural contexts, we may miss or delay pivotal opportunities to improve the physical health care in mental health settings.

Education and scope of practice

• UK: Mental health nurses are field specific registered nurses, with specialty qualification and training within their nursing education. This leads to a broad scope of practice within the specialism of mental health nursing care. Of note, the focus on mental health specialty impacts extent of education dedicated to physical health nursing care when compared to the Australian system.
• Australia: All registered nurses, including those working in mental health, undergo the same core nursing education program. This program may offer less emphasis on specific mental health or psychiatric training compared to the UK curriculum but may allow for broader foundational knowledge of physical health needs.

Professional development

• UK: mental health nurses in the UK have access to a wider range of specialised mental health professional development opportunities, fostering further specialisation within mental health and private practice. However, this focus may limit opportunities to transfer to other hospital wards or units as opposed to Australian nurses.
• Australia: while professional development avenues exist in mental health, they might be less readily available or require more individual initiative compared to the UK system. However, Australian nurses may have greater flexibility in transferring their skills to general hospital settings with less flexibility for private psychological care. Of note, that there are nil MBS-funded rebates/acknowledgement of capacity for the same for Australian nurses wishing to provide specialist psychological services in Australia.

Healthcare systems

• UK: The National Health Service (NHS) provides universal access to healthcare including mental health services.
• Australia: the Australian healthcare system is a mixed public-private model.