Enhancing Physical Health for SMI: A Comprehensive Literature Review

This literature review investigates methods to improve the physical health of individuals with serious mental illness (SMI), addressing the increased mortality and morbidity rates in this population due to chronic physical health issues. The review analyzes literature from CINAHL and Medline databases (2010-2019), identifying six relevant articles that highlight four key themes: the need for physical health training for staff, physical health monitoring, collaboration between healthcare staff, and the role of GPs and case managers in the physical care of people with SMI. The findings emphasize the importance of developing staff skills and providing educational resources related to physical health, as well as fostering collaboration with GPs and case managers to mitigate physical health risks. The review concludes by advocating for the application of these findings to improve healthcare practices for individuals with SMI and suggesting directions for future research to further enhance their well-being. Desklib provides access to this and other solved assignments to aid students in their studies.

Running head: MENTAL HEALTH
Topic: How physical health could be improved for people with serious mental illness?
Name of the student:
Date of submission:
Word count:

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Acknowledgment
I wish to acknowledge that conducting this particular research has been most
enriching experiences of my academic life as it increased my knowledge base and
analytical skills considerably. It provided me the opportunity to experience the new
challenges in research writing. All this, would be impossible without the dedicated
support that I have received from my professors, seniors and friends. I would like to take
this opportunity to thank my supervisor for his constant guidance and support and
encouragement. The constant support received from him has been extremely inspiring.
It has enlightened me with the thought process of the research.
Warmest wishes,
Yours Sincerely,

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Table of Contents
Abstract:.............................................................................................................................2
Introduction:.......................................................................................................................3
Background:.......................................................................................................................3
Methodology:.....................................................................................................................5
Findings:..........................................................................................................................12
Discussion: ......................................................................................................................12
Strength and limitation:....................................................................................................12
Conclusion: .....................................................................................................................12
References:......................................................................................................................13

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Abstract:
Aim: The aim of the research is to conduct a literature review to investigate about ways
to improve physical health of people with mental illness.
Background: The topic is considered important because of increase in mortality and
morbidity of patients with SMI because of chronic physical health issues. Poor physical
health for this group has been found because of many reasons and investigating
patient’s and staff’s perception regarding possible solution to minimize physical health
burden is considered important.
Methods: The extended literature review was done by conducting search for literature in
CINAHL and Medline database. Papers published between the year 2010 and 2019
was analyzed and the papers were selected based on screening and eligibility process.
The inclusion and exclusion criteria and review of full text helped to identify articles
eligible for the literature review.
Findings: Six articles were found relevant to the research question and it gave rise to
four themes. The four themes included need for physical health training of staffs,
physical health monitoring, collaboration between health care staffs and role of GP and
case managers in physical care of people with SMI.
Conclusion: The study gives the implication to develop skills of staffs and give them
educational packaged related to physical health. It suggests the need to collaborate with
GPs and case managers to reduce physical health risk for people with SMI.

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Abbreviation table:
SMI Serious Mental Illness
NHS National Health Service
DSM-IV Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition
PICO population, intervention, control and
outcomes
CASP Critical Appraisals Skills Programme
AGREE Appraisal of Guidelines for Research &
Evaluation Instrument
JBI Joanna Briggs Institute
PRISMA Preferred Reporting Items for Systematic
Reviews and Meta-Analyses

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Introduction:
Mental disorders like dementia, schizophrenia and others are regarded as one of
the leading cause of ill-health and disability worldwide. The magnitude of the burden is
understood from the increased risk of physical illness and high mortality rate in such
individuals (World Health Organization 2018). People with serious mental illness (SMI)
have been found to have higher rate of chronic disease compared to the general
population. The increased morbidity and mortality rates associated with SMI creates
additional burden for health care and nursing staffs (Walker, McGee and Druss 2015).
The common reasons cited for poor physical health includes service related factors like
inappropriate assessment, illness related factors stigma, poverty and cognitive deficits,
health behaviours such as smoking, poor diet and lack of exercise and obesity (Robson
and Gray 2007). This shows that paying attention to physical health of people with SMI
is critical and evaluating interventions to improve physical health is vital. The evidence
suggests the need to conduct in-depth exploration of research literature and find out
best possible ways to promote mental health of the target population review. Literature
review method can help to identify health promotion interventions that can be initiated at
the onset of the disorder. The extended literature review paper gives an insight into
background information on the research topic, rationale for conducting research in this
area and methods used to identify and extract information from relevant databases. The
research paper gives details regarding the key findings from thematic review and
implications and recommendations for practice improvement, education and
management. The most vital aspect that is covered through this literature review is that
it gives a conclusion regarding application of the findings to target population or target
setting and recommending future research needs.
Background:
Schizophrenia, bipolar disorder and major depressive disorder are types of
severe or serious mental illness (SMI) that contributes to long term care burden and
physical health issues for affected people (Lee, Rothbard and Choi 2016). Improving
health care provision for people with SMI need to be prioritized as this group has two-

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three times high mortality rate compared to the general population (De Hert et al. 2011).
Research evidence mentions that physical illness is the major contributor of excess
mortality rate as physical illness contributes to 60% of the death in people with SMI (De
Hert et al. 2011). Bartels and DiMilia (2017) indicates that people with SMI are
exposed to high rate of chronic physical health issues like diabetes, respiratory
disorders, cardiovascular disease and obesity, tuberculosis and HIV. Scott et al. (2016)
investigated about the association between DSM-IV mental disorders and 10 chronic
physical illnesses in 17 countries and statistically significant association was found. The
study confirmed that mental disorders of all types are associated with increased onset
of chronic physical illness. These data implies that these groups possess many unique
risk factors that make them susceptible to physical illness and current interventions for
the group are narrowly focused. As this would contribute to additional burden for mental
health nurses and people with SMI, researching on the reasons for such disparities and
finding the way forward to minimize physical illness in the group is important.
The evidence on physical illness in patients with SMI brings the question about
what might be the reason behind such health disparities in the population. De Hert et al.
(2011) justified that higher prevalence of modifiable risk factors itself is not the cause of
poor physical health of people with SMI. Instead such disparities are seen because of
disparities in health care access and utilization and health care provisions. Individual
lifestyle choices, psychotropic medications and psychiatric symptoms are the reason
behind disparities in health care. Another argument given by Vancampfort et al. (2015)
regarding the reason behind the high rate of mortality gap between patients with SMI
and the general population is that several risk factors combine to affect health of the
group such as physical inactivity and smoking. The use of anti-psychotic medication is
regarded as a burden of long term physical health conditions in the group. This is
supported by Thomson, Hall and Shah (2016) too which explains that antipsychotics
contribute to many physical health side effects. Other barriers to health in people with
mental disorders include cognitive problems, fragmented service, poor health literacy
and social isolation. Hence, this suggests that poor physical health associated with
mental illness is mainly due to inappropriate use of health care service and inadequate
quality of care. Physical health issues in people with SMI is considered an important

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research problem and conducting research in this area would help to identify useful
interventions to reduce the mortality gap and health status of the target population.
As there are many strong evidences regarding the prevalence of physical health
issues in patients with SMI and its impact on mortality rate, the rationale behind
focusing on this topic is understood. The research question that guides this research
process includes ‘How physical health could be improved for people with serious mental
illness?’. To find solutions to the research problem, it is necessary to evaluate whether
current treatment are accurate for the recovery of people with SMI or additional health
promotion tactics are needed to resolve the problem. The main aim of the research is
to evaluate interventions or strategies that could help to prevent physical illness in
people affected by serious mental disorder. Based on the research aim and objective,
literature review is considered the best method to evaluate interventions in mental
health practice. Extended literature review method can be the best option to investigate
about the topic as it can help in comprehensive assessment of interventions
implemented to improve physical health of people with SMI. It can help to explore new
ideas that may require further investigation and identify innovative ways to resolve the
research problem (Hart 2018). Literature review is necessary to embrace evidence
based practice and move one step ahead towards advancing quality and safety in the
specialty area of mental health. Smith and Noble (2016) revealed the significance of
literature review by reporting that it helps in summarize and interpreting large body of
research literature thus promoting evidence-based practice. Therefore, literature review
is likely to uncover answers to the research question and inform mental health care
professionals about the best available interventions to promote health and well-being for
people with SMI.
Methodology:
Introduction:
This section provides details regarding the methods used to search literatures
and find relevant articles for the review. The process of developing search question and
the search strategy used for retrieving articles has been discussed. The section gives

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details regarding summary of search process using PRISMA flow diagram, data
abstraction and method of data analysis.
Research question:
Framing of a research question is the first step towards identification of answers
to the research problem (Creswell and Creswell 2017). A well-formulated research
question is the backbone of research and it provides the context based on which the
research must be conducted. For this literature review, the background information
related to the topic helped to identify the research question. The focus was to make the
research very, concise and focused so that research process can be effectively
implemented. The success of a research is dependent on how well a research question
has been formulated. A well-formulated research question is one which is extremely
specific, precise and identified specifics research variables and population of interest
(Doody and Bailey 2016). There are many frameworks available to formulate a suitable
research question. The most popular framework includes the PICO (population,
intervention, control and outcomes) framework that facilitates identification of relevant
information. PICO based research question helps to address specific population,
intervention and the relevant effect of that intervention (outcome) (Aslam and
Emmanuel 2010). Hence, if the question is able to identify a specific research problem
and point towards aspects which are missing, then it offers good deal of support in
conducting research.
For this literature review, consideration of risk in people with SMI helped to
complex clinical question. The main population of interest identified was people with
SMI and the key research variables included treatment of physical illness in the target
population group. The research question that was framed after identification of specific
research variables was as follows:
How physical health could be improved for people with serious mental illness?
The review of the above research question shows that unlike PICO based
research question, here the focus is not to evaluate just one intervention. Instead the
research question favours exploration of different types of interventions and finding the

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best solution to promote physical health of the people affected by mental disorder. The
research question is suitable for an extended review as it would favour critical analysis
of those papers that suggest relevant intervention to address the burden of physical
illness in people with SMI.
Search strategy:
Formulation of keywords helped in searching for relevant articles in databases.
The important keywords were identified from the research question and the research
topic. The important keywords or phrases included ‘people with SMI’, ‘physical illness’,
‘management of physical illness and ‘treatment of physical illness in SMI’. After the
identification of keywords related to the research topic, other synonyms were used to
generate additional search terms. By the use of this approach other search terms found
for the literature review included ‘physical illness’, ‘chronic illness’, ‘intervention or
solution’, ‘health and well-being. As many database have advanced search filters,
Boolean operators like ‘AND’ and ‘OR’ was used to extract relevant research article.
‘AND’ was used when the purpose was to find both key terms in the research articles
and ‘OR’ was used to search for synonyms or alternatives in the same citation. Search
filters like year of publication and search field were modified to get relevant research
papers as per the inclusion and exclusion criteria. The following table shows how key
terms and concepts were combined to identify relevant articles for the literature review.
Concept 1 Concept 2 Concept 3

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AND ANDPhysical health
OR
Physical health
outcome
Improvement
OR
Management
People with mental illness OR
mentally ill people OR people
with schizophrenia OR people
with mental disorder
While conducting search for research literatures, it is necessary to search for
more than one database to obtain all relevant papers that contributes to the research
question. The choice of database in this review was influenced by the research topic
and research question. As the research is related to the issues faced in management of
the field of mental health, those database were taken which published peer-reviewed
journal articles from the field of nursing, biomedical and allied health field. Some of the
important databases that were used for search included PubMed and CINAHL. The
main rational behind selecting CINAHL was that it provided access to full text for
nursing and allied health journals. Hence, searching in this database can help to extract
relevant articles related to the study objective. In addition, PubMed was selected for
article searching as it publishes journal articles and online books from the field of life
science and biomedical, nursing and pharmacy. Google scholar was used to select
relevant articles because it is easily accessible and it does not have any complex
search filters or features.
Inclusion and exclusion criteria:
As the main of the extended literature review is to identify and assess all the
research papers that give detail on interventions to improve physical health in people

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with mental illness, the inclusion strategy was to select only those papers that reports
about interventions or strategies related to preventing physical illness. Any paper
reporting about experience of SMI people with physical illness was excluded from the
review as those papers may not serve the purpose of research. Any research paper
published in foreign language was excluded. However, there was no restriction to
selection of paper based on location and age group of research participants. An
overview of the inclusion and exclusion criteria for selecting relevant research papers
were as follows:
Participants Only those papers were included which had history or current diagnosis of
SMI like schizophrenia, dementia and personality disorders. Others were
excluded.
Intervention The selection of article was not limited to any intervention as the main goal
of the extended literature review was to identify interventions that could
promote mental health of people with mental illness.
Type of study
design
Paper selection was not limited to any specific study design too. All types
of research design such as experimental, cross-sectional and longitudinal
studies were included. Both qualitative and quantitative designs were
taken. However, secondary research designs such as systematic review
was least preferred.
Target outcome Another inclusion criterion for paper selection was that that all research
papers must report about ways to improve physical health and well-being
in people with SMI. Articles reporting about mental health outcomes were
excluded.
Target setting The inclusion of article was not restricted to any locality or specific country
of choice. All types of research setting and research done in any country
were included in the extended literature review.
Language Only those papers were taken which were published in English. Articles
published in foreign language were excluded.
Publication To ensure reliability of the research findings, only those papers were
included which were published between the year 2010 to 2019.
Data extraction:

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After searching for relevant research articles in the two selected databases, 105
articles were identified to be relevant to the research topic. More than 20 papers were
excluded after this as they were duplicates and covered the same findings with little
differences in publication date. To determine the eligibility of studies, the remaining
articles were first reviewed or screened by reviewing the abstract and title. At this stage,
30 papers were excluded because these papers did not have physical health outcome
as the main topic of interest and this was covered only in introductory part. After
selection of relevant papers, the second process of screening was started which
included review and comparison of the full text of the article based on inclusion and
exclusion criteria. At this point, articles were reviewed based on inclusion criteria set for
setting, population, outcome, type of study and language. Only those papers were
included which fulfilled the inclusion and exclusion criteria. At this point, many papers
were rejected which were duplicates. A total of 49 papers were removed or rejected
because the research was done on people with other illness or those investigating only
about perception about illness. Hence, six research articles were found suitable in terms
of inclusion criteria and research question. The summary of the search process has
been given by means of PRISMA flow chart below:

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Records identified through database searching
(n = 105)
Records after duplicates removed
(n = 20)
Records screened
(n = 85 )
Records excluded
(n = 30 )
Full-text articles assessed for
eligibility
(n = 55 )
Studies included in
qualitative synthesis
(n = 5 )
Studies included in quantitative
synthesis (meta-analysis)
(n =5 )
Full-text articles
excluded, with
reasons
(n = 49 )
Fig 2: PRISMA flow chart for search process
Data extraction is a step used in literature review or systematic review to
systematically arrange and summarize findings obtained from included research papers.
For each research papers, the summary of the research process was provided in a

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summary table. The summary table gave details on year of publication, research aim,
key findings and significance of the study. The summary table has been provided in
appendix A.
Data analysis:
Data analysis is most critical part of any research as it is the approach used to
summarize and analyze collected data. It involves the process of interpretation of data
using analytical reasoning to identify meanings, patterns and trends in a data
(Silverman 2016). As the main purpose of this paper is to conduct an extended literature
review based on research question, data analysis of selected paper has been done
using thematic analysis. Thematic analysis is an analytic method to identify patterns
across a data set and group common findings together to develop theme or sub-
themes. The themes have been developed by grouping studies with common findings
and collecting similar pattern results to develop a relevant theme (Vaismoradi, Jones,
Turunen and Snelgrove 2016). The selection of this approach is particularly relevant
with qualitative research method and based on the research question, it is evident that
the qualitative findings can be obtained. Thematic analysis can help to capture the
meanings within the data and identify communalities and differences in participant’s
description of subjective experiences (Crowe, Inder and Porter 2015).
Another vital element of thematic analysis is to conduct quality assessment of the
paper to understand the reliability and credibility of the evidence for application in real
setting. There are many critical appraisal tools that can be used to critically appraise
research literature such as CASP, JBI checklist, AGREE II and Cochrane Risk of Bias
tool. To assess reliability and generalisability of the evidence, CASP (Critical Appraisal
Skill Programme) tool was used. By the use of CASP checklist for different type of
studies, the quality of the papers was assessed (Buccheri and Sharifi 2017). This step is
relevant with the principles of evidence based practice as the utility of the evidence for
practice depends on ability to critically appraise information. This would help to achieve
the main objective of research and identify evidence based innovation to improve health
of patients with SMI. To ensure that high quality papers were kept and selected for the
literature review, the papers were assessed based on parameters like validity, reliability

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and generalisability of the study. Validity and reliability was done by assessment of
research rigour, review of possible biases in research and approach taken to remove
bias. Furthermore, generalizability of research finding was evaluated by assessment of
sample size and sampling technique (Noble and Smith 2015).
Summary of the articles found:
Six articles were found relevant to the research question. The summary table
provided in appendix 1 gives an insight into the summary of findings obtained from each
research article.
Findings:
The six articles identified for literature review was analyzed using thematic
analysis method. Thematic approach in research involves the process of examining and
recording patterns (themes) within research data. The advantage of using thematic
approach in data analysis is that it allows novice researchers to easily grasp the topic
and identify common patterns or findings in research paper (Smith 2015). The process
of theme development was done by first by reading the paper repeatedly and then
forming codes based on findings with similar pattern. Codes with similar patterns were
coloured and themes were searched from the coded data. The data which were relevant
to the research question were given specific theme names and the details regarding
each themes and the studies relate to the themes have been covered in this section.
Theme 1: Integrating physical health
Introduction:
The key issue for mental health nurse in providing care to diabetes patient is that
they lack the provision to provide physical care because of increased focus on mental
health outcomes. Hence, the review gave idea regarding articles that mentioned the
need for integrating physical health in mental health service to promote health of people
with SMI. There were two papers which reported about the need for training to promote
physical health of SMI patient. Happel, PLATANIA‐PHUNG, Gray, Hardy, Lambert,
McAllister and Davies (2012) acknowledged the value of physical health training to

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equip nurses with special skills and knowledge. Blanner Kristiansen, Juel, Vinther
Hansen, Hansen, Kilian and Hjorth (2015) conducted six focus groups to report about
the possibility of implementing physical health into daily psychiatric practice.
Integration of findings:
The article by Happel, PLATANIA‐PHUNG, Gray, Hardy, Lambert, McAllister and
Davies (2012) covered in this theme gave an outline regarding how mental health
nurses could be trained to improve physical health checkup for people with mental
illness. The study mainly investigated aboutnurses interest in training related to physical
health monitoring. Majority of participants regarded physical health monitoring as an
important intervention to improve physical health of older people. The study suggested
implementation of tertiary training for nurse to ensure that they adapt a physical care
role in mental health nursing. In contrast, focus group study done by Blanner
Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and Hjorth (2015) showed overlap of
themes was found for two focus groups and the main finding was that staff members
reported about collaboration between psychiatry and primary and secondary health
care. The two findings contrast with each other as one focused on integration of
physical health monitoring whereas emphasized on the need for collaboration.
Blanner Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and Hjorth (2015)
used focus group study to investigate about physical health problems in patients with
schizophrenia or substance use disorder. The study was done in three out-patient
clinics using qualitative research design and two focus groups were conducted in the
setting. The questions used in the focus group mainly included physical health
problems, cause of physical health problems, possibilities for treatment in general and
possibilities for treatment at out-patient clinic. As this research mainly aims to evaluate
possible interventions to treat physical health issues in people with SMIs, only possibility
for prevention and treatment section of result has been explored. The need for case
managers was expressed by patient. The difference in results of this paper compared to
Happel et al. (2012) is that it provides wider ideas regarding improving physical health
outcomes instead of just depending of physical health integration. However, work of
Blanner Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and Hjorth (2015) is

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consistent with the study by Mouko and Sullivan (2017), which suggested that short
term intensive training can train staffs and reduce the gap between physical and mental
health for persons with SMI.
Apart from the above two papers, Vasudev, Thakkar and Mitcheson (2012)
provided a tool to integrate physical health in mental health setting by investigating
about monitoring sheet. Mwebe (2017) provided the perspective of nurse related to
physical health monitoring, however it did not suggested way to integrate the same.
Ewart et al. (2016) gave no idea regarding improving physical health and van Hasselt,
Oud and Loonen (2013) suggested modifying organization structure to improve physical
health. However, detailed outcome was missing.
Conclusion:
Hence, training and skill development of nurse can be an effective pathway for
enhanced physical care and promotion of health of people with mental illness. However,
the critical appraisal of the article using the CASP (Critical Appraisals Skills Programme)
tool suggest that it is not a high quality research evidence as no research design and
sample population was used to achieve the desired findings. The findings cannot be
generalized because of lack of appropriate methodology and systematic approach taken
to collect data. In contrast to the study by Vasudev, Thakkar and Mitcheson (2012)
which did not considered motivational factors to improve lifestyle of mentally ill patients,
patients and staffs in the study by Blanner Kristiansen, Juel, Vinther Hansen, Hansen,
Kilian and Hjorth (2015) revealed about the need to have motivational factors for
physical activity.
Theme 2: Attitude towards daily monitoring
Introduction:
In relation to the problem of poor physical health outcome for people with SMI,
the literature review revealed that changing attitude of nurse towards daily physical
health monitoring is vital to promote physical health of people with SMI. Two qualitative
research papers reported about the need to monitor physical health parameters to

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improve health and well-being for people with severe mental illness. Vasudev, Thakkar
and Mitcheson (2012) gave a comprehensive detail of the benefits of monitoring by
introducing a physical health monitoring sheet, whereas Mwebe (2017) focused on
evaluating the perception of mental health nurse regarding physical health monitoring in
mental health settings.
Integration of findings:
Vasudev, Thakkar and Mitcheson (2012) reported about the efficacy of a physical health
monitoring sheet that was introduced in a 15-bedded forensic psychiatric rehabilitation
unit. The sheet was introduced in all patient’s record and the main aim was to prompt
health care professionals to collect information on various physical health parameters
like weight, body mass index, BP, result of blood test and smoking status. In contrast,
Mwebe (2017) explored about nurse’s role in the screening and monitoring of physical
care needs of people with serious mental illness. The difference between the two
studies is that the former used experimental approach to evaluate the potential of daily
monitoring which is more reliable and the latter used qualitative approach which would
serve to identify perceptions related to barrier and advantage of daily monitoring. Ewart
et al. (2016) gave no idea regarding improving physical health and van Hasselt, Oud
and Loonen 2013 just gave the recommendation to modify organizational structure to
achieve physical health improvement. Happel, PLATANIA‐PHUNG, Gray, Hardy,
Lambert, McAllister and Davies (2012) and Kristiansen et al. (2015) proceeded with the
concept of collaboration rather than physical health.
The utility of the findings obtained by Vasudev, Thakkar and Mitcheson (2012) is
that it gave insight about the clinical benefit of maintaining a physical health monitoring
sheet. After the introduction of monitoring sheets, large number of patients was
identified with risk factors like smoking, obesity and cardiovascular risk over the next 10
years. Identification of these risk factors helped professionals to give proper feedback to
patient and engage them in health lifestyle interventions in the ward. Hence, the study
was successful in demonstrating the main advantage of physical health monitoring
sheet and people who are at risk of poor physical health and those who needed urgent
attention. In contrast, Mwebe (2017) gave clear idea regarding nurse’s perception of

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barriers to physical health such as resource allocation, local culture and staff attitudes.
For example, nurses reported about challenges in implementing cessation program in
the wards. Another challenge was that nurses faced challenges in deciphering physical
health symptamatology of mentally ill patients. This finding can be useful in overcoming
institutional related barrier while integrating physical health monitoring. Another barrier
reported by nursing staffs included lack of clarity around referral pathways. This was
expressed by a nurse in the following way: ‘I do struggle to know who to refer to as
there is not a clear referral pathway identified’. The significance of this study is that by
investigating about barrier to physical health monitoring, the study revealed about
training needs for nurse too. For example, nurse reported of not attending any physical
health training in the past two years. The study gives the implication that adequate time
and investment is necessary to ensure that nurse build their confidence in physical
health monitoring. Abdallah, Conn and Marini (2016) revealed physical health
monitoring as an integral part of care for SMI.
Despite the results, the intervention by Vasudev, Thakkar and Mitcheson (2012)
cannot be regarded as very robust intervention because all patients were not motivated
to take part in lifestyle intervention. The strength of the study is that methodology
chosen was appropriate to eliminate any biases as adequate discussion regarding the
intervention and the way to use it was done with the medical and nursing staffs on the
ward. This helped to mitigate staff related barriers in implementing the intervention.
However, the limitation of the study includes small sample size and only single center
study which affects the generalizability of the research work. The research cannot be
applied unless it is done in other settings with larger sample size. However, the
credibility of the work is affected by small sample size and lack of heterogeneous setting
for research. In contrast, the main strength of the study by Mwebe (2017) is the use of
reflexive approach as it promoted clarity in client’s response. The sample size was
adequate. However, conducting the research in other wards with different mental ill
patients would have enhanced the quality and generalizability of the work. In case of the
study by Vasudev, Thakkar and Mitcheson (2012) too, the ward selected was too
specific and evaluating perception of staffs in other mental health setting was important.

20MENTAL HEALTH
Conclusion:
To conclude, the findings related to the the design of physical health monitoring
sheet is worth attention as by focusing on collecting information related to different
physical health parameters, the sheet provides the pathway to identify physical risk for
mentally ill patients.
Theme 3: Improving collaboration between health care professionals
Introduction:
Another important theme emerging from literature review included improving
collaboration to assess physical risk for patients with SMI. van Hasselt, Oud and
Loonen (2013) used qualitative research approach to assess the views of patients and
families related to the improvement of care for the physical health of patients with SMI.
Compared to Mwebe (2017) which conducted semi-structured interview with 10
registered mental health nurses to investigate about the issue, van Hasselt, Oud and
Loonen (2013) conducted the study with patients with SMI and their family carers. This
paper is more useful than Mwebe (2017) as by exploring view of both patients with SMI
and their family caregivers, the study gave played a role in identifying solutions both
from the perspective of staffs as well as patient. In addition, Ewart et al. (2016) used
focus group format that helped to recruit only those mental health consumers who have
concerns related to physical health care.
Integrating the findings:
van Hasselt, Oud and Loonen (2013) carried both group and individual interviews to
identify needs and preference of patient and family related to physical care for SMI. The
analysis of results revealed that patients experienced a barrier in making appointment
because of sense of inferiority and this affected the referral pathway. In addition, both
patient and family carers revealed that non-existent or sparse collaboration between
GPs and mental health carers. The participants regarded the role of GP as important as
they are contacted first for physical problem. However, different experiences where
reported by participants in the study by Ewart et al. (2016) as the semi-structured

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interview with 31 consumer participants revealed poor experience for consumers
because of scarcity of physical health, challenges in accessing treatment for physical
health problems and feelings of disappointment due to lack of appropriate support.
However, all the issue suggest collaboration between GP and mental staff as an
important strategy to achieve the desired support. Kristiansen et al. (2015) revealed
collaboration as a necessary strategy by analysis of nurses perspective. However,
Mwebe (2017) gave no evidence in relation to this theme. Happel et al. (2011) did not
introduced the strategy of collaboration to improve patient outcome.
The analysis of the perception of family carers and patients in the research done
by van Hasselt, Oud and Loonen (2013) and Ewart (2016) revealed many significant
ideas for improvement of physical health service for people with SMI. Firstly, the review
of barriers suggest that people with SMI are in need of strong support by health care
professionals as they are exposed to many specific vulnerabilities compared to other
population group. The review of barriers to effective physical care for people with SMI
suggests that professionals need to apply a more tailored approach while caring for
patients. Collaboration between mental care staffs and GPs would help to reduce gap
and improve access to physical care for patients with SMI. The study gives the
implication that investment in inter-professional consultation is important so that specific
health risk is identified for patients (van Hasselt, Oud and Loonen 2013). The strength
of the study is the adaptation of thematic analysis method to review participant’s
response and using narratives. Direct quotes from carers and patients made point very
clear. The sample size for the study was appropriate based on purpose of investigation.
Ewart et al. (2016) took appropriate sample for the study too. Sutton and Austin (2015)
explain that quotations from user-research participants are powerful form of qualitative
data and they provide real insight into the meaning of an event in participant’s own
work. The finding obtained by Ewart et al. (2016) is considered reliable because of the
use of appropriate research design. The main advantage of focus group is that broad
range of information can be obtained and details related to feelings and perception can
be easily explored through focus groups (Carey and Asbury 2016).
Conclusion:

22MENTAL HEALTH
To conclude, the examination of papers under this revealed not taking holistic
approach as one of the cause behind both physical and mental health issues ofor
patient. Instead, providers either focused on mental illness or they avoided considering
physical health issues in patients with SMI. The finding suggests the need to take novel
approach and promote collaboration between care providers to provide more effective
and equitable physical care to people with SMI. The rigour in research was understood
by consideration regarding data saturation. However, lack of participants from different
jurisdiction affected the generalizability of the research findings.
Theme 4: Organizing physical health care
Introduction:
The critical analysis of research articles gave solution regarding the way to
organize physical health care service in mental health care setting. There were two
studies which considered the role of case managers and GPs as important to improve
physical health of people with diabetes. van Hasselt, Oud and Loonen (2013) used
group and individual interview method to explore needs and preference regarding the
care of physical health parameters for people with SMI. The study revealed that family
carers preferred annual evaluation of the treatment plan with the case manager and GP.
Blanner Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and Hjorth (2015) indicated
that patients with SMI preferred cased managers for management of physical health.
Some significant result from the study by van Hasselt, Oud and Loonen (2013)
was that it recommended that GPs should pay unrequested house calls to people with
SMI. In addition, participants reported about the need for case managers to have
knowledge regarding specific health risk for patient to provide adequate support. By
focusing on exploring physical health problems and possibilities for prevention, similar
findings were reported by Blanner Kristiansen, Juel, Vinther Hansen, Hansen, Kilian
and Hjorth (2015) too. The study indicated case managers as an important preventive
approach to implement physical health into daily practice. Patients with mental illness
recommended that they could benefit if case managers provide support and help them
in adhering to physical activity, lifestyle choices as well as doctor appointments. Hence,

23MENTAL HEALTH
by acting as a personal adviser for patient, case managers can eliminate several
barriers for patient.
The difference in the above two papers is that only van Hasselt, Oud and Loonen
(2013) introduced the role of GP and this was not considered by Blanner Kristiansen,
Juel, Vinther Hansen, Hansen, Kilian and Hjorth (2015). However, the reliability of the
suggestion is enhanced as van Hasselt, Oud and Loonen (2013) gave evidence
regarding the lack of appropriate visit to the GP despite presence of physical health
problem. Hence, skill gap of GP and case manager and the potential to improve their
skill was suggested by the study. The strength of the study is that it is consistent with
other research study as Bressington et al. (2018) reported that case managers were
pessimistic about their ability to improve physical health of people with SMI. Hence, the
negative attitude of case manager is a concern and this research could pave way for
identifying new solution to manage physical health issues in patient. However, the
credibility of the work is compromised by the use of convenience sampling method. This
might contribute to selection and taking a heterogeneous sample groups would have
enhanced the credibility of the work. Inappropriate sample size is found as a limitation
for the research by Blanner Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and
Hjorth (2015) too. Another limitation of the study methodology is that as six focus
groups were taken, it was necessary to consider data saturation aspect. However, this
was not done and there is a possibility that more themes and important results might
have been obtained. The diversity of the result is affected because the moderator
interrupted the discussion if the participants went beyond the topic during the interview.
Hence, there was a need for robust research design to ensure that the data is free from
any biases and misconceptions.
Conclusion:
This theme reported about studies that revealed the role of case managers in
promoting health of SMI people. By detailed description regarding the type of case
managers they want, the literature review is successful in defining the attributes needed
by a case manager to successfully manage physical illness in patients with mental
illness. This included knowledge and competencies related to physical activity and

24MENTAL HEALTH
nutritional issues and communication skills. The result was obtained by conducting six
focus groups with patients and staff from out-patient clinics.
Discussion:
From the critical review of six research articles, four prominent themes emerged
(Integrating physical health, Attitude towards daily monitoring, improving collaboration
between health care professionals and organizing physical health care). The literature
review has helped to identify several solutions to improve physical health outcome of
people with mental illness. The overall review mainly suggest that nurses alone are not
enough in promoting physical health, instead the participation of the broader health care
team is needed to achieve positive health outcomes for patients with SMI.
A prominent theme coming up in most of the paper was the need for integrating
physical health monitoring to identify risk and take appropriate action for target
population group. For example, four papers by Happel et al. (2012), Blanner
Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and Hjorth (2015), Vasudev,
Thakkar and Mitcheson (2012) and Mwebe (2017) directly or indirectly mentioned about
the need for physical health assessment to identify risk and plan appropriate treatment
for people with serious mental disorder. Happel et al. (2012) reported about the need to
increase attention to physical elements of care. The study pointed out to the problem of
lack of access to physical health risk assessment and care as a major problem in
Australia. The similarity of this research finding with that of Blanner Kristiansen, Juel,
Vinther Hansen, Hansen, Kilian and Hjorth (2015) is that it suggested incorporation of
physical health in mental care setting. The underlying reason behind this
recommendation was the fragmentation of the current treatment system. However,
difference in both the evidence exists in relation to the outlook to resolve the problem.
For example, Happel et al. (2012) emphasized more on the need to expand the skills of
nurse so that mental health can be delivered with a renewed focus on physical care. In
contrast, Blanner Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and Hjorth (2015)
emphasized more on collaboration with health care team to promote physical health
monitoring.

25MENTAL HEALTH
There are many important implications coming up from the work of Happel et al.
(2012) and Blanner Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and Hjorth
(2015). The study by Happel et al. (2012) gives the implication to modify the nursing
curricula so that nurses come equipped with skills related to physical health monitoring.
The study gave direction to develop skills of those nurses who are already in the field.
This included short term training related to delivery of physical health care. Blythe and
White (2012) argues that nurses are in a prime position to reduce unacceptable death in
people with SMI. Happel et al. (2012) claimed regarding lack of physical health risk
assessment and fragmentation of the service. This finding is supported by Blythe and
White (2012) which revealed that that mental health nurses express role ambiguity as
they are not provided routine training and health care education. Hence, training mental
health nurse in physical health care and developing their attitude to positively engage
with patients is identified as an effective solution to promote health of people with SMIs.
White, Hemingway and Stephenson 2014) have demonstrated positive effect of
evidence based education package to enhance physical health literacy in mental health
nurse. Nurses attending the session demonstrated significant knowledge gain and
willingness to apply learning to practice. Similar robust and brief evidence based
education package needs to be developed in real mental health setting too. The findings
influence the action of management as their commitment will be essential to implement
this solution.
Vasudev, Thakkar and Mitcheson (2012) gave the recommendation to use
physical health monitoring sheet to improve health of people with SMI. Compared to the
above two papers, the significance of this paper is that gives an insight into how
physical health monitoring can be practically enhanced in clinical setting. The
introduction of the sheet is a significant contribution of this research as it gives the
implication regarding the way to enhance physical health monitoring without additional
training for nurses. The researcher used physical health monitoring sheet as a prompt
to regularly monitory physical health parameters. Some of the positive outcomes that
emerged after the introduction of the sheet included high rate of identification smokers
and patients at risk of cardiovascular events. One year follow-up revealed 100 % record
update related to physical health on the sheet. This resulted in shift or significant

26MENTAL HEALTH
reduction in cardiovascular risk for patients. Despite limitations like small sample size,
the article indicated about barriers in the introduction of the sheet. For example, many
patients refused to undergo waist measurement and blood test. Hence, the study gives
the suggestion that both GPs as well as nurse take the joint responsibility so that such
monitoring sheets can be implemented without any disruptions. It gives the implication
to the health care management to implement a process to initiate appropriate lifestyle
modification programme for those patients who are at risk of critical physical health
issues. Health care managers can consider implementing simple web based tools that
can encourage participants of patients without any objection. Looijmans et al. (2017)
supported that web tool are objective source of information that can attract the attention
of both patient and nurse in relation to unhealthy lifestyle behavior and risk for patient. It
can give guidance regarding healthy options for patients too.
Another vital theme or solution identified through literature review included
improving collaboration between health care professionals to promote physical health of
people with SMI. van Hasselt, Oud and Loonen (2013) and Ewart et al. (2016)
suggested similar solution to overcome the issue of mortality and care burden due to
risk of physical illness in patients with SMI. Both the studies were similar in the area of
research methodology too. The inference was done by conducting focus group
interviews with participants and using thematic approach to analyze findings. Another
similarity was that both had mental health consumers as the research participants. This
implies that the intervention of improving collaboration between staffs is a
recommendation that has been voiced by mental health consumers. This finding should
be considered very important as it would help to address current limitation that exist in
mental setting and upgrade practice related limitations too. In the study by van Hasselt,
Oud and Loonen (2013), thematic analysis of study findings indicated lack of
collaboration among health care professionals as a major burden for patient as they had
to go through repeated assessment because of this issue. Previous research
literatureshows lack of interprofessional collaboration as a major issue. Andvig, Syse
and Severinsson (2014) suggested that well-functioning team should coordinate
knowledge, skills and efforts to perform a task.

27MENTAL HEALTH
Furthermore, Ewart et al. (2016) revealed several inherent problems in the
mental health care setting. For example, semi-structured focus groups response
indicates that scarcity of physical health problem, disempowerment and non-responsive
health system is a major concern for mental health consumers. The important
conclusion made by the study was that it gave implication for the enrolment of specialist
nurse so that all kinds of physical health services can be provided to students. The
findings give the implication to improve contextual barriers related to physical health
delivery in mental health setting. The proposed recommendation would help in providing
on-going physical health service to consumers and ensure that right treatment is
provided at the right time. As mental health service delivery is hindered by poor
coordinated responses, the study gives the implication to staffs and organization to
understand the definition of collaborative practice in mental care setting (Jones and
Delany 2014). Hence, investment is required in the area of professional time so that
interprofessional consultation can be implemented in health care setting. Collaboration
between GP and mental health staff is critical as most patients with SMI are treated as
out-patients. Coventry et al. (2015) emphasized that both patients and family carers
believe that there is an urgent need for collaboration between GPs and mental health
care. The findings have implications for health care leaders as they have the
responsibility to ensure that holistic care responsibilities are agreed between each
professionals. Any form of education and training for the health care team should focus
on identifying specific health risks. Mental health care professionals and GPs should
coordinate actions so that access of physical health care becomes easy for mental
health consumers. Mental health staffs should guide patient in obtaining necessary
health care from GP and GP should work to ensure that services are easily accessible
for group.
The thematic analysis revealed the potential of case managers and GPs in improving
physical health outcome of people with SMI. van Hasselt, Oud and Loonen (2013) and
Blanner Kristiansen, Juel, Vinther Hansen, Hansen, Kilian and Hjorth (2015) gave the
idea of keeping a case managers to handle physical health issues of mentally ill
patients. The evidence from these two paper suggest that physical health management
of SMI is dependent not only on the action of nurse; instead the role of other allied

28MENTAL HEALTH
health professionals like specialist staffs and case manager is critical in mental health
care setting. Hence, collaboration between primary and secondary health care would be
an approach to resolve health issues for the target population. Individual case
managers can empower mentally ill patients by bringing changes in their daily life as
well as health status. The outcome from this theme has wider implication of the health
management staffs as this recommendation can be realized only by the systematic
action of the management staffs.
Apart from the discussion regarding the important implications of the literature
review for practice, education and management, the review of the need for further
research in the area is important. All the six articles mainly used qualitative approach to
conduct research with staffs and mental health consumers. However, some
methodological limitations suggest the need for future research on the topic too. For
example, the limitations of the study by van Hasselt, Oud and Loonen (2013) and
Vasudev, Thakkar and Mitcheson (2012) included small sample size and lack of a
heterogenous sample. This implied that future research should focus on taking
appropriate sample size and conducting research in diverse type of mental health
setting to collect additional views regarding reducing physical health burden in people
with mental illness. Selection biases were found in most of the studies as convenience
sampling was used thus affecting the credibility of finding. Lack of consideration of data
saturation aspects in focus group studies suggest the need to conduct a qualitative
research that considers all confounding factors and take adequate steps to address
them too. Future research can focus on identifying the impact of case managers on
physical health of people with SMI. This would develop understanding regarding
barriers and facilitators of this intervention. This would favour smooth application of
solutions to mental health settings.
Strength and limitation:
The main purpose of this report was to understand what method can be used to
promote physical health of patients with SMI. The extended literature review used
certain inclusion and exclusion criteria to identify relevant research articles on the topic.

29MENTAL HEALTH
The major strength of this literature review is the selection of qualitative research
papers. All the six articles had qualitative research design and they gave insight into
varied opinion of staffs and patients regarding the approach needed to improve physical
health. This helped to develop many themes and identify key issues in practice too.
Qualitative research paper looks deeper into an issue by recording feelings and
opinions of the person (Bryman 2017). Some of the articles selected used direct quotes
from participants which made data more comprehensive and easy to understand too.
Hence, this enabled not only identification of the opinion of participants regarding
strategies to improve physical health, but the reason behind such opinion.
Another strength of this literature review is the use of CASP tool to critically
appraise the quality of research papers. Using CASP tool to understand the validity of
research method and generalisability of the findings ensured that the literature review
had valid arguments and practical steps that is needed to implement the intervention in
actual setting is identified. This form of quality assessment adds value to research and
enables research to understand results and level of confidence in the findings (Harrison
et al., 2016). Apart from the strength, there are certain weaknesses of this systematic
literature review too. Due to lack of time, all sections of the CASP tool was not
completed. The focus was on review of research design and generalizability of findings.
Hence, data collection approach and clarity in research reporting was not extensively
analyzed.
Conclusion:
The extended literature review aimed to identify and analyze research papers
that could give idea about ways to reduce long term burden of physical health issues for
people with SMI. By conducting search in PubMed and CINAHL database, the six
articles were found relevant to the research question. The repeated review and thematic
analysis of research papers gave rise to four themes. These themes included
integrating physical health, Attitude towards daily monitoring, improving collaboration
between health care professionals and organizing physical health care. The critical
review revealed physical health monitoring as one of the dominant theme. This theme

30MENTAL HEALTH
reflected lack of attention to physical health and poor skills of nurse as a major
weakness in current mental health setting. The implications drawn from theme 1 and
theme 2 were that developing skills of nurse in relation to physical health is necessary
to promote health of people with SMI. The papers suggested possible ways to enhance
physical health monitoring by the introduction and analysis of a physical health
monitoring sheet in mental health care. The findings gives implications for action of the
health care managements staffs so that useful educational package and ongoing
support for existing staffs can be implemented in order to conduct effective physical
health assessment and provide timely treatment to people with SMI. Another major
theme of the literature review was improving collaboration between health care
professionals and the papers by van Hasselt, Oud and Loonen (2013) and Mwebe
(2017) mainly pointed out to the need for collaboration between GPs and mental health
care staffs to address the accessibility issues for people with SMI. The theme related to
case managers and GPs suggest that recruitment of specialist staffs who could address
physical health needs of individual patients. Hence, strengthening physical health
infrastructures and skills of mental care staffs is the way to achievement of positive
physical health outcome for people with SMI. However, certain methodological
limitations in the research suggest the need to conduct future research to understand
the benefit of involving case managers in clinical setting.

31MENTAL HEALTH
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36MENTAL HEALTH
Appendix:
A. Summary table for the selected articles:
Articl
e no.
Author Researc
h
method
Research
aim
Key findings Significanc
e of the
study
Population
1. Blanner
Kristiansen, C.,
Juel, A., Vinther
Hansen, M.,
Hansen, A.M.,
Kilian, R. and
Hjorth, P., 2015
Qualitativ
e study
with
focus
group
To explore
physical
health
issues and
their cause
in people
with SMI
and
identify
treatment
and
prevention
from the
perspectiv
e of
patient
and staffs.
Weight
issues,
obesity and
cardiovascular
disease were
some of the
physical
health issues
found in SMI
group and the
causes
included
lifestyle,
organizational
problem and
mental
disorder.
Prevention
proposed
included
implementing
physical
health into
daily
psychiatric
practice.
As it
provides
perspective
on ways to
preventing
diabetes,
analysis of
the paper is
critical to
meet
research
objective.
Patient with
schizophre
nia or
substance
abuse
disorder
and staffs
from out-
patient
clinics
2. Ewart, S.B.,
Bocking, J.,
Qualitativ
e
To
investigate
The interview
with focus
The
significance
Mental
health

37MENTAL HEALTH
Happell, B.,
Platania-Phung,
C. and Stanton,
R., 2016
explorato
ry design
using
Semi-
structure
d focus
groups
about the
experience
of mental
health
nurse in
utilizing
health
services
related to
physical
health
needs
group
revealed that
scarcity of
physical
health
services,
problems in
accessing
service,
feelings of
disempowerm
ent and
physical
illness crisis.
of the paper
is that by
investigatin
g about the
experience
of nurse, it
gives
insight into
key
challenges
faced and
possible
change or
developmen
t need in
practice
setting to
improve
physical
health of
people with
SMI.
nurse
3. Happell, B.,
PLATANIA‐
PHUNG, C.,
Gray, R., Hardy,
S., Lambert, T.,
McAllister, M.
and Davies, C.,
2011
Summar
y
How
mental
health
nurse can
be
empowere
d to
improve
physical
health of
people
with SMI
The study
revealed that
nurse can
improve
physical
health of
people with
SMI by
checking
physical
symptoms,
delivering
It gave
guidance to
reduce
inequality in
health
provisions.
Nurse and
people with
mental
illness

38MENTAL HEALTH
physical
health advice
to patient and
liaising with
medical
practitioners
4 Mwebe (2017). Qualitativ
e
explorato
ry study
To explore
nurse’s
view
regarding
monitoring
of physical
care
needs of
people
with SMI.
The
participants
were
committed to
health
screening.
However, they
suggested
about the
need to
update skills
and get
additional
education and
training to
improve care
provisions.
The paper
is significant
as this
would help
nurse to
play an
active role
in
promoting
health and
well-being
for people
with SMI.
Mental
health
nurse
5. van Hasselt, Oud
and Loonen
2013
Qualitativ
e
explorato
ry study
design
To assess
views of
patients
and
families
regarding
improvem
ent of care
for
physical
health of
The research
identified
three themes
to improve
physical
health. This
included lack
of
collaboration
among
general
The study
has the
potential to
identify the
pathways
needed for
identificatio
n of
physical
health
needs of
Patient and
families
with SMI

39MENTAL HEALTH
patients
with
mental
illness
practitioners
and mental
health care
professionals,
lack of
patient’s
ability to
identify their
own physical
health needs
and
challenges in
implementatio
n of healthy
lifestyle.
people with
SMI and
improve
collaboratio
n between
GP and
mental
health care
professional
s
6 Vasudev,
Thakkar and
Mitcheson
(2012)
Qualitativ
e study
To
examine
the
feasibility
of a
physical
health
monitoring
sheet in
patients
record and
its impact
on patient
with SMI
after one
year.
Cardiovascula
r risk and
serum lipids
were reduced.
However, no
changes were
seen for BMI,
obesity,
smoking
status and
hypertension
The
significance
of the paper
is that it
gives idea
regarding
the utility of
physical
health
monitoring
sheet in
screening of
cardiovascu
lar risk in
patients
with SMI
Patients
with SMI

40MENTAL HEALTH