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Meeting of minds

When mental illness meets the medical ward. 

The complexity of providing treatment to patients who suffer from both physical and mental illness is well recognised. People who experience mental illness have a disproportionate rate of physical comorbidities, such as cancer, diabetes and cardiovascular disease. Navigation of the potential negative attitudes, environmental barriers and organisational factors that impact care provision should be a healthcare priority.

Mental illness is ranked as one of the top ten disabling illnesses worldwide; comprising 13% of the total global burden of disease. A disproportionate rate of morbidity and mortality are associated with mental illness. For example, people with schizophrenia or depression have a 40–60% increased risk of dying prematurely because they are less likely to seek health care for conditions such as diabetes, cancer, HIV/AIDS and cardiovascular disease. Having a mental illness interacts with the person’s physical condition and vice-versa: for example, depression may predispose diabetes and diabetes may contribute to the onset of depressive symptoms.

Care issues for people who experience mental illness are not isolated to mental healthcare settings; people experiencing mental illness are often also admitted to acute care settings such as the emergency room, medical-surgical units and other medical specialty wards. People who experience this physical and mental comorbidity often have difficulty seeking and accessing appropriate and timely physical healthcare due to a number of factors, including poor help-seeking behaviours as a consequence of psychiatric symptomatology or the fear of stigma attached to having a mental illness. Subsequently, their experience of care can be poor, resulting in increased complications, longer stay and more adverse events.

The challenges to the management of the physical care of people with physical and mental comorbidities are often related to the perpetuating stigmatising and cautionary attitudes held by healthcare professionals towards people experiencing a mental illness. Stigma related to mental illness exists in the general community and can filter into healthcare services, despite healthcare professionals having requisite medical knowledge about mental illness. As a result, healthcare professionals who are in regular contact with people who experience mental illness can inadvertently play a role in contributing to the effects of stigma towards mental illness by the use of derogatory and pejorative labels.

A recent systematic review related to nurses’ perceptions of treating patients with comorbid mental illness in a general hospital setting revealed evidence to suggest the nurses’ experience in caring for these patients was overwhelmingly negative. The nurses described the experience as challenging and difficult, with some patients displaying challenging/aggressive behaviours and often disrupting ward routines and/or threatening nurses’ safety. While nurses are well placed in the healthcare system to advocate against stigma of mental illness, it appears they too experience caution or fear of these patients.

Nurses can feel inadequately prepared to manage the mental healthcare needs of patients who present for physical health care. Nurses lacking the required resources, knowledge and skills to effectively care for this vulnerable group of patients, often generate strong feelings of inadequacy. Potentially, suboptimal care is delivered because of “fear of saying the wrong thing”, or by practicing cautious care. Furthermore, while many nurses feel a sense of responsibility in the context of their duty of care, a number of generalist adult-care nurses consider mental health care out of their scope of practice.

The available evidence shows that nursing staff support the idea that patients with comorbid mental illness did not belong on general wards due to the increased demands of these patients’ needs. These attitudes often interrupt care practices, where patients with a mental illness are often avoided and addressing interventions for mental health care are omitted, with physical health care often taking priority.

Limitations and restrictions in the clinical environments create barriers to providing effective care for patients experiencing mental illness. These acute-care environments often lack adequate privacy, can be noisy and routine observations are regularly required. Patients experiencing mental illness often require a private, low-stimulus environment to engage in therapeutic conversations with staff or to be in a therapeutic milieu to aid recovery. A noisy, open ward does not provide this type of environment and is therefore a potential barrier to providing care.

Organisational factors that can moderate negative attitudes include education and increasing exposure to mental health, positive role modelling and use of mental health resources. Increasing education, improving environmental factors and providing adequate support to healthcare professionals need to be primary considerations to augment care practices in acute care settings. We argue that as healthcare professionals are required to undertake an annual competency in basic life support, mental healthcare knowledge should be treated with the same prioritisation.

Given the large proportion of the population experiencing mental illness, standard and mandatory annual training for all healthcare professionals in mental healthcare competency including mental health literacy, risk management, environmental safety, psychopharmacology and therapeutic communication should be the priority.

Jo-Ann Giandinoto is a Research Assistant in the Nursing Research Unit at St Vincent's Private Hospital Melbourne. Associate Professor Karen-leigh Edward is from Australian Catholic University and St Vincent’s Private Hospital Melbourne.

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