YAPNU-50966; No of Pages 7

Archives of Psychiatric Nursing xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

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

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

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

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

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

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

Please cite this article as: Knight, M., et al., Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and
Psychological Empowerment, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.07.001
2 M. Knight et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx
confidence in assessment skills, but did not reflect an increase confi-
dence in the application to their clinical practice (Terry & Cutter, 2013).
Conversely, Mangurian et al. (2013) reported in a study of primary
care providers, that 40% were unaware of guidelines for patients on sec-
ond generation antipsychotics. The primary care providers identified
obstacles for monitoring risk factors for Met S including the degree of
psychiatric illness, the dilemma of working with psychiatrists and the
complexities of planning mental health outpatient care. Overall, better
coordination is needed between primary care and mental health pro-
viders in determining who is responsible for monitoring metabolic
parameters.
Nash (2014) conducted a small qualitative study of mental health
service users' perception of diabetes care received within the mental
health system. Identified factors which impeded treatment were stig-
ma, the attribution of physical symptoms to mental illness, delay in di-
agnosis of diabetes while exhibiting symptoms which required a
medical hospitalization, and lack of coordination between physical
and mental health services. The study participants noted that although
mental health nurses were knowledgeable, there appeared to be a lim-
ited ability of the nurses to translate practical interventions for diabetes
care. This important study further reported that inpatient mental health
nurses endorsed the value of physical health assessment of persons
with SMI and viewed this as a function of their roles. However, there
was a range in their confidence scores from being very confident for
obtaining vital signs, weight measurement and glucose checks to a less-
er confidence level with reviewing physical and mental health histories
and lifestyle patterns. They reported no confidence in their ability to re-
view laboratory results.
The literature supports that nurses are knowledgeable regarding the
need for physical assessment in the person with SMI, however this as-
sessment is often not being implemented within their practice (Bolton
et al., 2016; Howard & Gamble, 2011). Howard and Gamble (2011) fur-
ther report that while valuing physical health screening and assess-
ments, nursing documentation in the medical record did not reflect
this. Barriers within the workplace that may be affecting the psychiat-
ric-mental health nurse's ability to fulfill their role in health screening
and assessment need to be evaluated.
A Swedish study reported that mental health workers endorsed and
valued the use of EBP, however there was a reduction in the ability and/
or readiness to incorporate the evidence in their actual practice
(Engström, Jacobson, & Martensson, 2015). The adoption of EBP is
significant for nursing and the mandate to integrate best practices
into clinical decision making is essential (Stevens, 2013). The transfer
of evidenced-based research to practice is facilitated through the use
of clinical guidelines for the nurse to tailor to the individual's need.
Majid et al. (2011) reported 64% of nurses reported positive attitudes
toward EBP however barriers within the workplace impeded their
application to practice. The barriers to using EBP cited by nurses
included a lack of time due to caseloads and staffing shortages, diffi-
culty accessing resources, and limited support (Majid et al., 2011;
Melnyk et al., 2004).
Other authors have noted organizational barriers such as time con-
straints, perception of not being able to change one's practice, insuffi-
cient knowledge and skills related to EBP, lack of mentors, and lack of
resources and support from administration (Gerrish & Clayton, 2004;
Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2009). Additional
barriers not previously reported by nurses were unavailable informa-
tion and opposition from other nurses, physicians and nurse managers
(Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). These
cited barriers point to how the cultural norms of an organization can im-
pact practice.
Kanter's (1993) theory of Structural Power explains how employee
behaviors may be more influenced by work place conditions rather
than personal characteristics. Kanter details that the role of power and
the capability to get the work done originates from structural conditions
and not the individual attributes of the employee. According to this
Please cite this article as: Knight, M., et al., Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and
Psychological Empowerment, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.07.001
theory, positions with formal power are prominent, essential to the mis-
sion of the organization, and permit discretion in decision making. In-
formal power stems from relationships among co-workers to facilitate
completing the work (Kanter, 1993). Laschinger (1996) described
Kantor's theory of Structural Power in relation to nurses' work environ-
ments, and Purdy, Laschinger, Finegan, Kerr, and Olivera (2010) note
that the lack of empowerment in workplace settings impacts patient
satisfaction, nurse satisfaction and nurse retention.
Empowered employees need access to resources in order to fulfill
their responsibilities. A comprehensive literature review on workplace
empowerment and nurses' job satisfaction reported that an empowered
workplace promoted a professional practice environment, enhanced job
satisfaction and affirmed the caliber of patient care (Cicolini,
Comparcini, & Simonetti, 2014). Laschinger, Gilbert, Smith, and Leslie
(2010) proposed a nurse/patient empowerment model that suggests
when nurses are empowered within their work environment with ac-
cess to support, information and resources, they in turn empower
others, including their patients. While structural empowerment within
organizations has been described as a significant factor related to em-
ployee behavior, the need for nurses to be empowered to make deci-
sions, developing the blueprint for their work environment and
opportunities for professional growth and development were identified
as essential elements for enhancing patient safety, (IoM, 2004). Nurses
need to be able to manage their practice. This has been recognized by
the profession over the last several decades.
Being empowered to direct ones' practice activities can also impact
patient care. Menon defined psychological empowerment as “a cogni-
tive state characterized by a sense of perceived control, competence
and goal internalization” (Menon, 2001, p.159). The focus is on the
employee's experience of empowerment based upon enabling strate-
gies implemented by the organization. The three empowering compo-
nents are a sense of perceived control, which fosters an ability to
influence ones' work environment, perceived competence whereby
one believes they are capable to meet the work demands, and lastly,
goal internalization of adopting the vision and values of the organiza-
tion (Menon, 2001).
Laschinger, Finegan, and Wilk (2009) noted the working relation-
ship between the nurse manager and nursing staff is crucial in fostering
an empowering practice environment. The nurse manager facilitates ac-
cess to resources for goal attainment, sets the professional tone of the
environment, and supports decision making for patient care; in this
study, structural empowerment supported psychological empower-
ment. Wang and Liu (2015) discussed the impact of psychological em-
powerment as a means of increasing the nurses' confidence in their
ability and knowledge to accomplish their work. For example, the inte-
gration of new graduate mental health nurses into the work environ-
ment is influenced by the relationships between senior nurses and the
multidisciplinary team. This opportunity for dialogue provides an
empowering supportive learning environment, which fosters profes-
sional growth and confidence in the mental health nurse (Wright,
Lavoie-Tremblay, Drevniok, Racine, & Savignac, 2011).
PURPOSE
In a previous study the researchers noted that mental health nurses
knowledge of the evidence regarding metabolic risks and related mon-
itoring and treatment of persons with SMI did not translate well into
practice (Bolton et al., 2016). Therefore, this study sought to explore at-
titudes, confidence and barriers in providing physical health care for
persons with SMI who are at risk for or are experiencing Met S and if at-
titudes, confidence and barriers were related to whether physical care
activities were routinely conducted in practice. Finally, we explored
whether nurses' perceived psychological empowerment or ability to in-
fluence practice related to Met S in their workplace was related to the
performance of physical care activities.
 M. Knight et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx
METHODS
A survey design was used to collect data from a sample of the Amer-
ican Psychiatric Nurses Association (APNA) membership via the APNA
social media website. An adapted version of the Physical Health Attitude
Scale (PHASe) (Robson & Haddad, 2012), and an adapted version of the
Menon Empowerment Scale (Menon, 2001) were included in the
survey.
Procedures
We obtained permission to use and adapt the PHASe (Robson &
Haddad, 2012) and the Menon Empowerment Scale (Menon, 1999;
Menon, 2001); IRB approval from the University of Massachusetts Low-
ell was also obtained. With permission, a message from the researchers
with a link to the survey was posted on the APNA networking site,
Member Bridge, along with a detailed explanation of the study. Four re-
minders to complete the survey were posted at specified intervals dur-
ing the summer of 2015.
Measures
Mental health nurse physical health attitude scale (PHASe)
Robson and Haddad developed and described the PHASe in 2012.
The PHASe has four subscales related to the physical health care of per-
sons with SMI. The four subscales are attitudes to involvement in physical
health care, nurses' confidence in delivering physical health care, perceived
barriers to physical health care and nurses' attitudes toward smoking
(Robson & Haddad, 2012, p. 78). The final measure consisted of 28
items. The authors reported a Cronbach's alpha of 0.765 for the entire
scale and subscale values of 0.61 to 0.86 (Robson & Haddad, 2012).
With permission from the authors, we adapted the 28 item PHASe,
to reflect attitudes about care needed by individuals who have SMI
and are at risk for, or who are experiencing Met S or type 2 diabetes.
The Adapted Mental Health Nurse Physical Health Attitude Scale
(APHASe) contained 20 items; in three subscales: nurses' attitudes to in-
volvement in physical health care, nurses' confidence in delivering physical
health care, and perceived barriers to physical health care. We included
only one question in the fourth component of the PHASe, Nurses Atti-
tudes Toward Smoking, (“clients should not be encouraged to give up
smoking as they have enough to cope with”). We eliminated 12
questions that were not associated with Met S or diabetes such as
“Ensuring clients are registered with a dentist should be part of the
mental health nurse's role” and “mental health nurses should pro-
vide clients with contraceptive advise”. We added four questions
specifically related to attitudes about and confidence in providing
care to individuals with Met S and we altered one to specify confi-
dence in identifying those psychotropic drugs which increase meta-
bolic risk. Respondents were asked to rate each of the 20 question
separately on a Likert scale from 1–strongly disagree to 5–strongly
agree. The Cronbach's alpha for all 20 items in the current study
was 0.79 and the three subscales (not including the one question
related to smoking) ranged from 0.67 to 0.76.
A 15 item physical care activity survey was also included in the per-
mission to use the PHASe which identifies frequent physical care activ-
ities in the nurses' clinical practice (Robson, Haddad, Gray, & Gournay,
2013). We also modified this survey to reflect care activities related spe-
cifically to clients at risk for Met S which has been previously reported
(Bolton et al., 2016).
Menon empowerment scale
The Menon Empowerment Scale (Menon, 1999; Menon, 2001) was
developed to measure employee psychological empowerment across
three dimensions: perceived control, perceived competence and organi-
zational goal internalization. According to Menon an empowered em-
ployee has control over their work and its context, has competence in
Please cite this article as: Knight, M., et al., Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and
Psychological Empowerment, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.07.001
3
job performance and is energized by the goals of the organization
(2001, pg. 161). The final Menon Empowerment Scale has nine items,
three items in each dimension with Chronbach alphas ranging from
0.80 to 0.88 and retest reliabilities ranging from 0.77 to 0.87. Menon
noted that because the dimensions were only modestly correlated, the
scores could be added to obtain an overall empowerment score which
would reflect self-esteem, job involvement and organizational commit-
ment (Menon, 2001; Menon, 2002). Scores of 1–22 indicate low em-
powerment, 23–40 indicate moderate empowerment and 41–54
indicate moderate to high empowerment. In this study, the Menon Em-
powerment Scale was adapted with permission to reflect empower-
ment based on the management and care of individuals with
metabolic risk. The phrase, “patients with metabolic risk,” was added
to the end of each of the nine items on the Scale. In the current study
Chronbach alphas for the three subscales ranged from 0.83 to 0.926.
The Chronbach alpha for the entire scale was 0.869 (Menon, 2001).
Sample
The sample consisted of 154 nurses who accessed the survey, via the
APNA networking site Member Bridge. Not all members take advantage
of this site. A detailed description of the survey preceded the questions;
consent to participate was assumed by completion of the survey. One
hundred and seventy-five (175) members accessed the survey. Howev-
er, 21 surveys contained incomplete demographic data or missing re-
sponses on the various subscales. If only one item were missing from a
subscale, the mean score of remaining items on that subscale was
used to complete the subscale data. The results described are based
only on completed surveys. Table 1 describes the sample characteristics.
Data analysis
Survey data was analyzed using SPSS version 23. The data were
reviewed to assure completeness. First, as noted above, those surveys
with absent significant demographic data were excluded from the anal-
ysis and those surveys with more than one absent data point per sub-
scale were also excluded. For those respondents who missed only one
item on a subscale, the mean score of the other subscale items was en-
tered to complete the data set. Descriptive statistics described the sam-
ple, the responses to each of the APHASe (Table 2) and the Practice
Activities (Table 3) items. Because we included only one question relat-
ed to smoking, it is reported only in the descriptive data.
Pearson product moment correlations examined the relationship
between attitudes of involvement in physical care, confidence in the de-
livery physical care, perceived barriers to providing physical health care,
physical health care practice and workplace empowerment. We also ex-
amined the difference in education level and attitudes of involvement in
physical care, confidence in the delivery of physical care, perceived bar-
riers to providing physical health care, physical health care practice and
empowerment. An independent t-test compared the differences in
Table 1
Characteristics of the sample.
Mean SD Range
Age 55.3 10.65 24–76
Years MH nursing practice 20.61 13.27 1–49
Sex N %
Male 14 9
Female 140 91
Education level
Diploma/AD 13 8.4
BS/BSN 32 20.8
MS/MSN 84 54.5
DNP 13 8.4
PhD 12 7.8
4 M. Knight et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx

Table 2
Responses to APHASe.

Strongly Disagree Uncertain Agree Strongly

disagree N (%) N (%) N (%) agree
N (%) N (%)

Helping clients manage their weight should be part of the mental health nurses role 2 (1.3) 2 (1.3) 2 (1.3) 60 (39) 88 (57.1)
Giving nutritional advice to clients should be part of a mental health nurses role 1 (0.6) 3 (1.9) 5 (3.2) 61 84 (54.5)
(39.5)
I am confident in assessing signs and symptoms of hyperglycemia 6 (3.9) 21 (13.6) 73 54 (35.1)
(47.4)
It should not be the role of the mental health nurse to provide advice about exercise to clients 74 (48.1) 60 (39) 5 (3.2) 7 (4.5) 8 (5.2)
* Discussing risk factors associated with overweight and obesity should be part of the mental health nurses 1 (0.6) 3 (1.9) 67 83 (53.9)
role. (43.5)
Clients with serious mental health problems are not interested in improving their physical health 55 (35.7) 84 10 (6.5) 2 (1.3) 3 (1.9)
(54.5)
Giving advice on how to prevent heart disease should be part of the mental health nurses role 1 (0.6) 3 (1.9) 6 (3.9) 79 85 (42.2)
(51.3)
* Measuring waist circumference on a client who is on antipsychotic medication should be part of the mental 2 (1.3) 7 (4.5) 23 (14.9) 60 62 (40.3)
health nurses role. (38.6)
* Checking a client's record for laboratory findings should be part of the mental health nurses role. 44 110 (71.4)
(28.6)
I am confident that I can measure a client's blood-pressure accurately 2 (1.3) 41 111 (72.1)
(26.6)
* I am confident that I can measure a client's waist circumference accurately. 6 (3.9) 21 (13.6) 51 76 (49.4)
(33.1)
It is difficult to get clients to follow advice on how to manage their weight 3 (1.9) 16 19 (12.3) 99 17 (11)
(10.4) (64.3)
Clients should not be encouraged to give up smoking, as they have enough to cope with 74 (48.1) 70 3 (1.9) 4 (2.6) 3 (1.9)
(45.4)
Clients are not motivated to exercise 10 (6.5) 88 29 (18.8) 23 2 (1.3)
(57.1) (14.9)
Informing clients about the possible effects medication may have on their physical health will increase 20 (13) 90 31 (20.1) 12 1 (0.6)
non-adherence (58.4) (7.8)
It is difficult to get clients to follow healthy-eating advice 2 (1.3) 24 27 (17.4) 93 8 (5.2)
(15.6) (60.4)
I am confident in assessing signs and symptoms of hypoglycemia 5 (3.2) 14 (9.1) 81 53 (34.4)
(52.6)
** I am confident that I know which psychotropic drugs increase the risk for metabolic syndrome. 4 (2.6) 5 (3.2) 12 (7.8) 82 50 (32.5)
(53.2)
My workload prevents me doing any physical health promotion with clients. 21 (13.6) 92 18 (11.7) 17 (11) 6 (3.6)
(59.7)
Clients physical health worries are mostly due to their mental illness. 37 (24.0) 95 12 (7.7) 9 (5.8) 1 (0.6)
(61.7)

* Added items to the original PHASe.

** Adapted item to reflect risk for metabolic syndrome.

attitudes of involvement in physical care, confidence in the delivery
physical care, perceived barriers to providing physical health care, phys-
ical health care practice and workplace empowerment between two
groups based on level of education. Because of the unequal numbers
of nurses educationally prepared at various levels, nurses with under-
graduate preparation (Diploma, AD, BS) were combined to represent
Group 1 (n = 45) and those with graduate preparation (MS, DNP and
PhD) (n = 110) were combined to represent group 2.
A linear regression determined which factors related to the care of
persons with SMI (attitudes of involvement in, confidence in delivery
of, perceived barriers to providing physical health care and empower-
ment) accounted for involvement in care practices.

Table 3
Practice activities.

Never Rarely Often Very often Always

N (%) N (%) N (%) N (%) N (%)

Checking if clients have had their general physical health assessed within the past year. 8 (5.2) 18 (11.7) 32 (20.8) 33 (21.4) 63 (40.9)
Checking if the clients I work with are followed by a PCP. 5 (3.2) 8 (5.2) 30 (19.5) 36 (23.4) 75 (48.7)
Monitoring clients blood-pressure. 6 (3.9) 13 (8.4) 26 (16.8) 39 (25.3) 70 (45.5)
Giving clients advice on the benefits of exercising regularly. 3 (1.9) 18 (11.7) 43 (27.9) 66 (42.9) 24 (15.6)
Helping clients manage their weight. 4 (2.6) 42 (27.3) 51 (33.1) 46 (29.8) 11 (7.1)
Giving clients advice on how to eat healthily. 4 (2.6) 22 (14.3) 63 (40.9) 51 (33.1) 14 (9.1)
* Reviewing lab findings (lipids, HgbA1C, FBS). 3 (1.9) 11 (7.1) 31 (20.1) 56 (36.4) 53 (34.4)
* Measuring waist circumference routinely. 60 (39) 51 (33.1) 24 (15.6) 11 (7.1) 8 (5.2)
Weighing clients routinely. 9 (5.8) 24 (15.6) 37 (24) 46 (29.9) 38 (24.7)
Helping clients to stop smoking. 5 (3.2) 32 (20.8) 63 (40.9) 32 (20.8) 22 (14.3)
* Educating clients about risk for metabolic syndrome. 16 (10.3) 24 (15.6) 45 (29.2) 43 (27.9) 26 (16.9)
* Sharing information about risk factors with treatment team. 22 (14.3) 32 (20.8) 43 (27.9) 33 (21.4) 24 (15.6)
Making referrals for medical follow-up. 6 (3.9) 15 (9.7) 38 (24.6) 59 (38.3) 36 (23.4)

All other items from Robson et al. (2013).

* Items added for the current study.

Please cite this article as: Knight, M., et al., Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and
Psychological Empowerment, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.07.001
 M. Knight et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx 5

Table 4 females, and triglycerides N 150 mg/dL (Alberti et al., 2009). Because
Summary of intercorrelations, means, and standard deviations of scores of the phase com- of their increased risk, persons with SMI require careful screening and
ponents, Menon empowerment and practice activities.
evaluation at routine intervals as well as guidance around lifestyle be-
Attitude Confidence Barriers Practice Menon total haviors. Psychiatric-mental health nurses in all areas of practice are
activities score poised to intervene through routine monitoring and ongoing education.
APHASe In the current study 36% of the physical care activities related to the
Attitude – 0.429** 0.251** 0.437** 0.147 care and management of metabolic risk and/or syndrome including
Confidence 0.429** – 0.262** 0.380** 0.230**
monitoring of the above risks, were explained by attitude toward pro-
Barriers 0.251** 0.262** – 0.294** 0.241**
Practice activities 0.437** 0.380** 0.294** – 0.433** viding the care, confidence in providing care and the individual nurses'
Menon empowerment 0.147 0.230** 0.241** 0.433** – perceived psychological empowerment in the organizations where they
M 30.81 21.4 23.9 44.62 40 were employed. There were significant, yet low correlations among the
SD 3.27 2.71 3.47 9.6 8.3 variables; however the low-moderate collinearity suggests each vari-
Range 22–35 11–25 7–33 13–65 16–54
able contributed independently to the performance of physical care ac-
** Significant at p b .01. tivities. Examples of the physical care activities included monitoring
blood pressure, helping individuals manage their weight, educating in-
dividuals about the need for exercise, reviewing lab values and measur-
ing waist circumference. Many of these physical care activities are
RESULTS routine for mental health nurses. The level of nurse educational prepa-
ration was not associated with any of the variables in the current
Pearson product-moment correlation coefficients illustrated a small study (attitude, confidence, lack of perceived barriers in providing phys-
but significant relationship among several variables. Table 4 describes ical care, practice activities or perceived empowerment).
the correlations, means, standard deviations and ranges for the depen- In this study, attitudes toward physical care activities as part of the
dent and independent variables. Attitude toward providing physical nurse's role were positive; this is consistent with previous literature
health care to mental health clients was correlated with confidence in (Happell, Scott, Nankivell, & Platania-Phung, 2013; Howard & Gamble,
providing care (r = 0.429, p = 0.000); with perceived lack of barriers 2011; Verhaeghe, De Maeseneer, Maes, Van Heeringen, & Annemans,
in providing care (r = 0.251, p = 0.002); and with practice activities 2013). The mean score of 30.81(Table 4) indicates an overall belief
(r = 0.437 p = 000). Confidence in providing care was correlated that supporting clients to manage weight, nutrition, exercise and cardi-
with perceived lack of barriers in providing care (r = 0.262, p = ac health were all perceived as a component of the psychiatric-mental
0.001); with practice activities (r = 0.380 p = 0.000) and with per- health nurses' practice role. Further, the respondents in this study
ceived empowerment (r = 230, p = 0.004). Perceived lack of barriers expressed confidence in assessing weight, waist circumference and
toward providing care was also correlated with practice activities (r = signs of hyper or hypoglycemia (M-21.4). Confidence in the ability to
0.241, p = 0.003) and with empowerment (r = 0.433, p = 0.000). provide physical care is consistent with Howard and Gamble's study
There was no difference in attitude, confidence, lack of perceived (2011). Terry and Cutter (2013) note that education of psychiatric men-
barriers in providing physical care, practice activities or perceived em- tal health nurses increased their confidence in providing physical care
powerment when comparing the two groups based on education prep- activities.
aration (Diploma/AD, BS nurses Group 1 [n = 45] and MS, DNP, PhD Many nurses practice in larger organizations where the hierarchy
Group 2 [n = 110]). may play a role in determining responsibility and practice activities.
A linear regression was calculated to predict practice activities based This study looked at psychological empowerment (Menon, 1999) and
on attitudes toward providing physical care to clients with SMI, confi- while the nurses in this study perceived empowerment in their role
dence in providing physical care to clients with SMI and absence of bar- and were empowered by the goals of their organizations, this study
riers in providing care to clients with SMI and perceived empowerment did not address structural empowerment, the ability to accomplish
in the workplace. A significant regression equation was found (F (4, work with the requisite information, resources, opportunities and sup-
149) = 20.983, p b 0.000), with an R2 of 0.36. Attitude (β = 0.875, p b port (Kanter, 1993). Wagner et al. (2010) reviewed studies that delin-
0.01), confidence (β = 0.529, p b 0.05), and perceived empowerment eated a causal relationship between structural empowerment and
(β = 0.380, p b 0.01) each were significant predictors. Lack of perceived psychological empowerment within the nursing practice arena. The
barriers was not a predictor (β = 0.277, n.s.). Table 5 details the regres- merits of structural and psychological empowerment within the work
sion model. environment impacts the engagement of nursing staff (DiNapoli,
O'Flaherty, & Musil, 2016). Clearly both psychological and structural
DISCUSSION empowerment could impact practice activities significantly in hospitals,
clinics, community health centers and even in private practices.
Metabolic syndrome (Met S) and diabetes are serious risks for per- In addition, the movement of many U.S. health care organizations to-
sons with SMI. Five physiological factors are associated with Met S ward Magnet Status (recognition provided through the American Nurse
based on the International Diabetes Federation (IDF) criteria: increased Credentialing Center) focuses on improving patient outcomes and en-
waist circumference (N88 cm for females; N102 cm for males), elevated gaging nurses to incorporate evidence into practice. Developing a cul-
blood pressure (systolic blood pressure N 135 mm Hg, diastolic blood ture of inquiry (Breckenridge-Sproat et al., 2015), supported by nurse
pressure N 80 mm Hg), fasting blood sugar (FBS) N 100 mg/dL, high den- scientists and mentors (Duffy, Culp, Sand-Jecklin, Stroupe, & Lucke-
sity lipoproteins (HDL) b 40 mg/dL for males and b50 mg/dL for Wold, 2016) and driven by organizational commitment may also lead
to practice change within organizations. This further strengthens the
psychological empowerment of nurses. Yet in order to evaluate research
Table 5
and implement changes in practice, time, resources and organizational
Multiple linear regression for predicting physical care activities.
infrastructure are needed (Berger & Polivka, 2015). Happell, Platania-
Variable B SE β t p VIF Phung, and Scott (2014) note that organizational factors have a signifi-
Attitude 0.875 0.215 0.299 4.066 0.000 1.258 cant influence on whether physical health care is provided by psychiat-
Confidence 0.529 0.264 0.150 2.008 0.046 1.296 ric-mental health nurses. Providing time, resources and identifying
Barriers 0.277 0.193 0.100 1.430 0.155 1.142 responsibilities within roles may influence organizational practices re-
Empowerment 0.380 0.079 0.331 4.824 0.000 1.097
lated to Met S.

Please cite this article as: Knight, M., et al., Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and
Psychological Empowerment, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.07.001
6 M. Knight et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx
LIMITATIONS
There were two major limitations in this study, First, the sample
came from the membership of one professional organization and does
not represent all psychiatric mental health nurses in the U.S. More
than half of the sample were prepared at the graduate or doctoral
level which does not mirror the proportion of psychiatric nurses in prac-
tice. Second, this research did not consider structural empowerment
which may play an important role in practice activities. Further research
is needed to address structural empowerment and its role in the perfor-
mance of physical care activities by psychiatric mental health nurses.
CONCLUSIONS
The results of this study have significance for all nurses who care for
those with SMI across settings. Met S, diabetes, and cardiovascular dis-
ease are serious conditions which reduce quality of life and longevity
for persons with SMI. The American Diabetes Association (2004),
along with several other organizations, developed a consensus state-
ment for the care of persons on second generation antipsychotic medi-
cations. The guidelines note the importance of determining baseline
assessments and routine follow-up monitoring of height, weight,
waist circumference, lipid profile and fasting blood glucose. In addition
to monitoring, a holistic approach utilizing strong alliances with all pro-
viders involved in the care of persons with SMI is needed. It is well
known that linkages between psychiatric care and physical health care
can be problematic (Jones et al., 2016) yet these linkages are essential
in the long term care of persons with SMI. Furthermore, there is still a
lack of consensus regarding who should assume the primary role.
Many argue that mental health providers, who see their clients more
frequently, should assume a larger role in monitoring metabolic risks.
While the care of persons with SMI is interdisciplinary, practice models
utilized in the care of persons with SMI must be re-evaluated. “Out of
the box” thinking to develop models engaging all care providers active-
ly, including psychiatric-mental health nurses, other mental health and
primary care clinicians as well as nutritionists and fitness professionals
to care for the whole person must become the new norm. Health care
organizations must re-evaluate the emphasis placed on health care inte-
gration and develop care models which assist the psychiatric-mental
health nurse to be an empowered and active participant, incorporating
evidence based strategies into caring for this vulnerable population.
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Please cite this article as: Knight, M., et al., Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and
Psychological Empowerment, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.07.001