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International Journal of Mental Health Nursing (2020) , – doi: 10.1111/inm.12755

O RIGINAL A RTICLE
Physical health assessment and cardiometabolic
monitoring practices across three adult mental
health inpatient units – a retrospective cohort study
Rebekah Howard,1,2 Lisa Kuhn,3 Freyja Millar4 and Maryann Street1,5
1 2
School of Nursing and Midwifery, Deakin University, Geelong, Eastern Health, Adult Mental Health Services,
3
School of Nursing and Midwifery, Monash University, 4Outcome Health, and 5Centre for Quality and Patient
Safety Research - Eastern Health Partnership, Melbourne, Victoria, Australia

ABSTRACT: Australians with lived experience of mental illness die on average 10 or more years
earlier than the general population. Cardiometabolic disorders, including cardiovascular disease and
diabetes mellitus, are common causes of premature death in this cohort. Little is known about
cardiometabolic monitoring practices in mental health inpatient units. The aim of this study was to
examine the characteristics of cardiometabolic monitoring and physical health assessments of adult
mental health consumers within the first 72 hours of admission to an inpatient unit. We implemented
a retrospective descriptive exploratory design by medical record audit. Data were collected using a
pre-validated audit tool, adapted with recent literature and policy, from a randomly selected sample
of consumers admitted to three acute mental health adult inpatient units of a large Australian
metropolitan health service in 2016. Of 228 consumers, the mean age was 37.5 (range 18–64) years
and 51.3% were women. Cardiometabolic risks were common, yet most consumers received
incomplete cardiometabolic monitoring. While few consumers (15%) were diagnosed with
cardiometabolic comorbidities, 67.5% were prescribed psychotropic medications with high
cardiometabolic risk. Compliance with recommended cardiometabolic monitoring varied
considerably between risk factors: for example, blood pressure was measured in 56.1% of consumers,
whereas waist circumference was never recorded. There were no statistically significant associations
between cardiometabolic monitoring completion and sex or cardiometabolic risk. These findings
demonstrate the need for increased education and awareness of cardiometabolic risk and identify a
critical gap between physical health assessment practices and recommendations for this cohort.
KEY WORDS: adult, cardiometabolic monitoring, mental health, risk factors, waist circumfer-
ence.

CorrespondenceRebekah Howard, Deakin University, School of Nursing and Midwifery, Geelong, Upton House, Eastern Health, 131
Thames street, Box Hill, Victoria 3128, Australia. Email: Rebekah.Howard@easternhealth.org.au
Declaration of conflict of interest: Rebekah Howard was granted a publication prize award from Deakin University to support this publi-
cation. There are no further disclosures required.
Authorship Statement: All authors listed have made substantial contributions to the conception, design, analysis, and interpretation of the
data used for this work. All authors had the opportunity to comprehensively review and revise the work in close collaboration. All authors
listed have reviewed and approved the completed manuscript accompanying this document and agree to be accountable for all aspects of
the work, including its accuracy and integrity.
Rebekah Howard, RN (Hons), BHsc.
Lisa Kuhn,RN PhD MHSc GDNur EmergCert DipAppSci(Nur), Associate Professor of Emergency Nursing.
Freyja Millar, RN MHN DE MNursP MNursP(NP), Primary Care Mental Health Nurse Practitioner.
Maryann Street, PhD, BSc (Hons), Grad Dip Drug Eval & Pharm Sci, Senior Research Fellow.
Accepted May 25 2020.

© 2020 Australian College of Mental Health Nurses Inc.

2 R. HOWARD ET AL.
INTRODUCTION
It is increasingly being recognized that people with a
lived experience of mental illness have disproportion-
ately high rates of cardiometabolic related morbidity
and mortality compared to the general population
(Behan et al. 2015; De Hert et al. 2011; Galletly et al.
2016; McEvoy et al. 2005). Metabolic syndrome is a
clinically significant indicator of future cardiometabolic
comorbidities (Galletly et al. 2012). The second Aus-
tralian National Survey of Psychosis revealed that over
half of participants with a psychotic disorder between
the ages of 18 and 64 years met criteria for metabolic
syndrome (Morgan et al. 2011). In a large meta-analysis
by Vancampfort et al. (2015), just under a third of par-
ticipants diagnosed with severe mental illness (SMI)
were at significant risk of metabolic syndrome
(P = 0.001) (Vancampfort et al. 2015). Metabolic syn-
drome is estimated to occur in between 13.4% and
30% of the Australian general population (Galletly
et al. 2012). Internationally, the prevalence of meta-
bolic syndrome within the general population is 18%
(Vancampfort et al. 2015).
The frequency and characteristics of cardiometabolic
monitoring (CMM) and physical health assessment for
mental health consumers across health settings are
commonly reported to be inconsistent with local and
international best practice guidelines (De Hert et al.
2011; Mitchell et al. 2012). People with a lived experi-
ence of mental illness are more likely to experience
multiple cardiometabolic risk factors than those without
these illnesses. Factors contributing to excessive car-
diometabolic risk in this group include genetic and
pathophysiological risk, demographic and socio-eco-
nomic risk, lifestyle risk, and treatment-related risk sec-
ondary to antipsychotic and other psychotropic
medications (Galletly et al. 2016).
Mental health services are accountable to consumers
in supporting them with both mental health and physi-
cal health concerns, including provision of routine
CMM (Galletly et al. 2016). Several local (Hetrick
et al. 2010), national (Galletly et al. 2016), and interna-
tional (Laugharne et al. 2012) physical health assess-
ment guidelines have been published, though there has
been variable translation of recommendations into
practice (Kreyenbuhl et al. 2017).
In 2016–2017, there were 164,060 admissions for
consumers requiring specialized mental health services
in Australian public hospital inpatient units (IPUs)
(AIHW 2018). Acute mental health IPUs are
environments that allow comprehensive assessment and
coordination of physical health care while consumers
receive treatment for acute mental health concerns
(Batscha et al. 2010; Rosenbaum et al. 2014). Few
studies have examined the frequency and nature of
CMM and physical health assessment within the IPU
setting. Of the few available studies in IPUs, all
demonstrated low concordance with CMM practices.
Though previous studies have measured CMM parame-
ters sporadically, and commonly in small samples of
consumers (Batscha et al. 2010; Brown et al. 2018;
Mitchell et al. 2012; Rosenbaum et al. 2014). Further
examination of CMM practices for mental health con-
sumers in inpatient settings is required to inform evi-
dence-based solutions focused on improving the quality
of care (Okkels et al. 2013).
The aim of this study was to examine the character-
istics of CMM and physical health assessment of adult
mental health consumers within the first 72 hours of
admission to a mental health IPU. Specific objectives
were as follows:
1. To determine the frequency and characteristics of
CMM and physical health assessment undertaken
for mental health consumers within the first
72 hours of admission.
2. To identify staff documentation practices in relation
to cardiometabolic risk factors and cardiometabolic
comorbidities.
3. To examine alignment of staff practices with
accepted Australian recommendations at the time.
METHODS
Setting
The study was conducted at three adult IPUs within
one of the largest health services in metropolitan Mel-
bourne, Australia. These three units combined had 75
acute mental health beds.
Sample
Adults admitted to one of three IPUs during a six-
month period from January 1st to June 30th, 2016
were eligible for inclusion in the study. Consumers
were excluded if they were under 18 years or over
65 years of age, pregnant, had a length of stay less than
72 hours, were transferred between IPUs, or became
absconded during the first 72 hours of admission.
© 2020 Australian College of Mental Health Nurses Inc.
PHYSICAL HEALTH AND CMM IN THREE INPATIENT UNITS 3

A population of 1201 consumers admitted within the
study’s timeframe was randomized by the health service
data unit prior to release of the dataset to the research
team, with a sample of 361 consumers provided. A sam-
ple size of 280 consumers was calculated to enable anal-
ysis of the data with 95% confidence according to
Naing, Winn and Rusli’s (2006) formula, based on the
proportion of consumers who received comprehensive
CMM in a study of mental health consumers in the
community of 24%. (Millar et al. 2014). In estimating
sample size, a precision (d) of 0.05 enabled the preva-
lence of cardiometabolic monitoring to be estimated
with confidence in statistical significance set at 10%
(Naing et al. 2008). However, using the exclusion crite-
ria described, 134 consumers were ineligible for inclu-
sion in the study (Fig. 1), and the number of eligible
cases was 228. With the guidance of a biostatistician,
post hoc power calculations undertaken, assuming an
alpha of 0.05, showed that 228 cases led to a negligible
decline in precision (d) of the estimates from 0.050 to
0.056 with corresponding increase in the confidence
interval from 10% to 11% (Naing et al. 2006). Hence, a
sample of 228 consumers was sufficient to provide reli-
able estimates of cardiometabolic monitoring with statis-
tical significance in the current study.
Data Collection
An audit tool was developed specifically for implementa-
tion in this study, adapted from a previously validated
audit tool (Millar et al. 2014), and using available litera-
ture and CMM guidelines (Galletly et al 2016). The pre-
sent study’s tool was titled the Inpatient Cardiometabolic
Monitoring Audit Tool (ICMMAT) (see Appendix S1).
The ICMMAT is a 33-item CMM and physical health
assessment audit tool enabling focused collection of data
for consumers admitted to mental health IPUs. The nat-
ure of cardiometabolic risk is often dynamic with an inter-
play of multiple risk factors, therefore, the ICMMAT was
designed to collect data on a wide range of variables,
including social, demographic, care-coordination, diag-
nostic, and treatment-related variables, as well as CMM
the primary researcher with no changes required. Con-
tent and face validity of the audit tool was assessed by
mental health professionals from related disciplines
including mental health program managers and senior
executives, psychiatrists, psychiatric registrars, associate
nurse unit managers, clinical nurse educators, and the
first author of the previously validated tool (Millar
et al. 2014). Those who returned feedback on the
ICMMAT agreed on its relevance, usability, and com-
prehensiveness as a measure of CMM within an inpa-
tient setting, with no substantive changes suggested.
Data analysis
Data were validated using Microsoft Excel (Microsoft
Office) and SPSS Statistics version 23.0 (IBM Corpora-
tion 2012) and cross-checked by two members of the
research team (M.S. and R.H.). Data were summarized
as descriptive statistics to obtain frequencies, means,
medians, and interquartile ranges (IQR). Relationships
between sex and socio-economic, demographic, clinical,
and CMM variables were analysed using cross-tabula-
tions and chi-square test or Fisher’s exact test for sta-
tistical significance (Fisher & Schneider 2013). A
biostatistician was consulted to confirm the appropriate
statistical tests were used.
An indicator of CMM completion was necessary due
to the multitude of parameters that comprise complete
CMM. Blood pressure was selected as a proxy indicator
1201 consumers
admitted in study
period
361 consumer Excluded = Aged over 65 = 2
records from health 134
service Discharged or
transferred in less
than 72 hours =
100
AWOL during the
Included = 228
first72 hours of
admission = 4

and physical health assessment.

Admitted outside
January 1st and
June 30th, 2016 =
Reliability and validity 21
To increase reliability and validity, a data dictionary
was devised and reviewed by the research team to Missing
documentation =
ensure uniform collection of data across medical 7
records (Gregory & Radovinsky 2012) and the ICM-
MAT was successfully piloted on a subset of data by FIG. 1: Inclusion and exclusion criteria. AWOL, absent without
leave.
© 2020 Australian College of Mental Health Nurses Inc.
4 R. HOWARD ET AL.
of minimal CMM and physical assessment completion
because it is an important measure encompassing both
cardiac and metabolic function (Alberti, Zimmet, &
Shaw, 2006) and was one of the most frequently com-
pleted parameters. While blood glucose levels are an
important indicator of metabolic assessment (De Hert
et al. 2011), these were not documented in a sufficient
number of cases to allow reliable statistical analysis.
Hence blood pressure alone was used.
Ethics
This study adhered to the guidelines for ethical
research set out by the National Statement published
by the National Health and Medical Research Council
(NHMRC 2007). Ethics approval for the low-risk study
was granted by the health service and the university.
As a retrospective audit of care that had already been
provided, the study met the criteria for Waiver of Con-
sent; hence, participant consent was not required
(NHMRC 2007).
RESULTS
The cohort of 228 consumers had a median age of 37
(IQR = 28-47) years and was evenly distributed by sex
and across sites of admission. Women were more fre-
quently diagnosed with personality disorders (26.5% vs
11.7%, P = 0.005) and less often with psychotic disor-
ders (53.8% vs 71.2%, P = 0.007) than men. Women
more often resided in private accommodation (49.6%
vs 30.6%, P = 0.015), while men were more likely to
live with family (23.9% vs 40.5%, P = 0.015). A minor-
ity of consumers were diagnosed with cardiometabolic
comorbidities (15%, n = 34) and while men had higher
rates than women (19.3% vs 11.1%), this difference
was not significant (P = 0.087; Table 1).
All but one (99.6%, n = 227) of the study cohort
were prescribed psychotropic medications (Table 2).
The most commonly prescribed category of psychotropic
medications were anti-anxiety medications (96.9%,
n = 220). Antipsychotic medications were prescribed to
89.5% (n = 204) of the cohort, with 88.6% (n = 202) of
consumers prescribed second-generation antipsychotic
(SGA) medications, and 15.4% (n = 35) prescribed first-
generation antipsychotic (FGA) medications. Overall,
52.2% (n = 119) of the cohort were prescribed more
than one antipsychotic medication, indicating antipsy-
chotic polypharmacy (Kukreja et al. 2013). There was no
difference in the frequency of antipsychotic medication
polypharmacy between sexes (P = 0.584).
Second-generation antipsychotic medications known
to have high cardiometabolic risk (olanzapine and cloza-
pine) were prescribed for 67.5% (n = 154) of the cohort
(Table 2). The proportion of consumers prescribed SGA
medications associated with moderate cardiometabolic
risk was 19.7% (n = 45), 12.7% (n = 29) were pre-
scribed either no SGA medications or SGA medications
considered to be of low cardiometabolic risk. There was
no statistically significant difference between women
and men regarding cardiometabolic risk of prescribed
antipsychotic medications (P = 0.132). Most consumers
(86.8%, n = 198) were prescribed at least one physical
health medication, and 12.7% (n = 29) were prescribed
five or more medications to treat physical conditions,
defined as polypharmacy (Masnoon, Shakib, Kalisch-
Ellett, & Caughey, 2017).
Completion of CMM varied between 56.3% (for
physiological observation measurements) and 0% for
measurement of waist circumference, with no signifi-
cant difference between sexes. Rates of diagnostic
pathology testing were less than 10%. There were no
significant differences between women and men for
completion of lifestyle assessments. Lifestyle assess-
ment completion ranged from 38.6% for smoking
assessment, to 2.6% for exercise assessment (Fig. 2).
Just over half of consumers had physiological observa-
tions measured once every 24 hours within the first
72 hours of admission (heart rate 56.3%, n = 125; tem-
perature 54.0%, n = 121). Rates of partial completion of
physiological observations across the timeframe studied
were over 40%. Few consumers (2.7%, n = 6) declined
CMM measurements, and only 0.8% (n = 2) did not have
any physiological observations documented during the
first 72 hours of IPU admission. Several socio-economic,
demographic, clinical, and diagnostic variables appeared
to impact blood pressure completion. Statistically signifi-
cant relationships were found between blood pressure
completion and site of admission (P = <0.001), prescrip-
tion of FGA medications (P = 0.049), and prescription of
antidepressants (P = 0.049). No statistically significant
associations were found between blood pressure and car-
diometabolic risk or comorbidities (Table 3).
DISCUSSION
Frequency and characteristics of CMM and
physical health assessment
Cardiometabolic comorbidities are highly prevalent in
people with a lived experience of mental illness and
contribute to inequitable health outcomes and
© 2020 Australian College of Mental Health Nurses Inc.
PHYSICAL HEALTH AND CMM IN THREE INPATIENT UNITS 5

TABLE 1: Consumer characteristics, N = 228 TABLE 2: Categories of psychotropic medications prescribed

n % Total Cohort

Site of admission n %
Upton House 69 30.3
Anti-anxiety 220 96.9
IPU1 83 36.4
Antipsychotic medication 204 89.5
IPU2 76 33.3
Second-generation 202 88.6
Consumer age
No/low† cardiometabolic risk 29 12.7
18-44 156 68.4
Moderate cardiometabolic risk‡ 45 19.7
45-65 72 31.6
High cardiometabolic risk§ 154 7.5
Consumer sex
First-generation 35 15.4
Women 117 51.3
Antidepressant 85 37.4
Men 111 48.7
Mood stabilizer 55 24.1
Living Situation
Other¶ 13 5.7
Private 92 40.4
Family 73 32.0 †Low cardiometabolic risk second-generation antipsychotic (SGA)
Homeless 30 13.2 medications include lurasidone, asenapine, aripiprazole, ziprasidone,
Other† 33 14.5 amisulpride.
Income ‡Moderate cardiometabolic risk SGA medications include queti-
Centrelink 160 70.8 apine, risperidone, paliperidone.
Employed 66 29.2 §High cardiometabolic risk SGA medications include olanzapine
Not documented‡ 2 1.8 and clozapine.
Insurance ¶Other psychotropic medications include acamprosate, buprenor-
Public 210 92.1 phine, clonidine, methadone, naltrexone, and suboxone. Consumers
Private 18 7.9 can be included in more than one category due to prescription of
Mental health diagnosis§ multiple psychotropic medications.
Psychotic disorder 142 62.3
Mood disorder 81 35.5
Personality disorder 44 19.3
Multiple diagnoses 58 25.4
Other¶ 24 10.5
Cardiometabolic disorder diagnoses§ national rates for people with lived experience of men-
Hypertension 18 7.9 tal illness (Harris et al. 2018). Our findings suggest that
Diabetes 14 6.1 consumers without an established diagnosis prior to
Dyslipidaemia 13 5.7 admission to an IPU may have had screening omitted.
One or more cardiometabolic comorbidities
Whether this reflected actual rates of pre-existing car-
None 191 84.9
One 25 11.1 diometabolic disorders among the cohort or resulted
More than one 9 4.0 from incomplete documentation is unknown.
Physiological observations, including blood pressure,
†Other living situation includes supported residential services,
heart rate, and temperature were documented for just
caravan parks, and Department of Health and Human Services hous-
ing. over half of consumers, comparable to the rates
‡Not documented treated as missing data, not included in analy- reported in Brown and colleagues’ recent interventional
sis. study of CMM in an Australian inpatient setting
§Consumers can be included in more than one category due to (Brown et al. 2018). No consumers in our study had
dual diagnoses and comorbidities.
waist circumference measurements taken. Similarly,
¶Other mental health diagnoses include adjustment disorder,
post-traumatic stress disorder (PTSD), complex PTSD, generalized Brown et al. (2018) found waist circumference was
anxiety disorder, obsessive compulsive disorder, situational crisis, measured at a rate of less than one per cent pre-inter-
intellectual disability. vention. Organ et al. (2010) also reported that waist cir-
cumference was rarely performed despite providing
premature mortality in this group (De Hert et al. 2010; tape measures to all staff for this purpose. In our study,
Galletly et al. 2016). This study demonstrated that peo- body measurement parameters were completed in
ple with SMI received inadequate and incomplete under one-quarter of consumers, despite local policy
CMM within the first 72 hours of admission to a men- mandating completion of height and weight measure-
tal health IPU. ments on admission to mental health IPUs. Besides the
Documented rates of pre-existing cardiometabolic advantages of cost-effectiveness and ease of measure-
comorbidities found in our study were below reported ment (Rosenbaum et al. 2014), waist circumference is

© 2020 Australian College of Mental Health Nurses Inc.

6 R. HOWARD ET AL.

Exercise assessment
Diet assessment
Smoking assessment
Fasting lipid profile
Fasting blood glucose
HbA1c
Random BGL
Waist circumference
Height
Weight
ECG
Temperature
Respiration rate
Heart rate
Blood pressure
SpO2
0% 10% 20% 30% 40% 50% 60%

FIG. 2: Frequency and characteristics of cardiometabolic monitoring and physical health assessment undertaken for mental health consumers.
BGL, blood glucose level; ECG, electrocardiogram; HbA1c, glycosylated haemoglobin; SpO2, peripheral saturation of blood oxygen.

the best clinical indicator of central adiposity and car-
diometabolic risk (Alberti et al. 2006; Parrinello 2012;
Rosenbaum et al. 2014). Clinicians and consumers have
previously reported feeling uncomfortable with the
physical contact involved in measuring waist circumfer-
ence, though these reports depended predominantly on
the level of familiarity with technique (Barber et al.
2014). In response to the perception of staff within an
inpatient setting that consumers were uncomfortable,
Rosenbaum et al. (2014) studied the rate at which con-
sumers declined measurement of waist circumference
and found negative staff perceptions were overstated,
as only two out of 180 consumers declined the assess-
ment (Rosenbaum et al. 2014).
Increased cardiometabolic risk portends to develop-
ment of metabolic syndrome, which establishes an
environment of chronic inflammation and oxidative
stress, resulting in dysfunction within adipose tissues
(Holt & Mitchell 2015; Parrinello 2012). As dysfunc-
tional adipose tissue gathers around the waist, inflam-
matory, and oxidative mediators are released and
perpetuate further metabolic disturbances, culminating
in increased mortality (McCracken et al. 2018; Par-
rinello 2012).
Stanton et al. (2017) investigated whether waist cir-
cumference was truly required to detect metabolic syn-
drome in mental health consumers (Stanton et al.
2017). They found that without waist circumference,
metabolic syndrome went undetected in one-third of
consumers (Stanton et al. 2017).
A crucial finding of our study was that CMM was
completed at inadequate rates for mental health con-
sumers in inpatient settings, which is concordant with
local and international literature (Batscha et al. 2010;
Hetrick et al. 2010; Kreyenbuhl et al. 2017; Laugharne
et al. 2016; Millar et al. 2014; Mitchell et al. 2012;
Okkels et al. 2013; Velligan et al. 2013). Considering
the well-documented disproportionate risk of car-
diometabolic comorbidities and associated mortality
(Galletly et al. 2016; Harris et al. 2018; Lambert et al.
2017; Vancampfort et al. 2015), these findings illustrate
that the rights of people with SMI are undermined by
mental health services’ failure to provide them with
access to health care on par with the general popula-
tion (Australian Government National Mental Health
Commission 2016).
Documented risk factors for cardiometabolic
disorders and comorbid conditions
Differences between sex and the prevalence and type
of cardiometabolic comorbidities have been previously
reported (Galletly et al. 2012; Harris et al. 2018; McE-
voy et al. 2005); however, CMM completion was not
influenced by sex in the current study. Social disadvan-
tage has been associated with increased rates of con-
current mental and physical health conditions (Harris
et al. 2018; Smith et al. 2013); but income sources and
living situations were not statistically associated with
CMM completion. The frequency of mental health

© 2020 Australian College of Mental Health Nurses Inc.

PHYSICAL HEALTH AND CMM IN THREE INPATIENT UNITS 7

TABLE 3: Consumer characteristics by blood pressure completion† TABLE 3: (Continued)

Yes No Yes No
X2 (df) P- X2 (df) P-
n % n % value n % n % value

Site of admission 22.182 (2) Highǂ metabolic risk SGA 0.768 (1)
<0.001* medications 0.381
IPU 1 29 35.8 52 64.2 Yes 80 54.1 68 45.9
IPU 2 49 64.5 27 35.5 No 44 60.3 29 39.7
Upton House 46 71.9 18 28.1 Moderate cardiometabolic risk 0.087 (1)
Diabetes 0.190 (1) SGA medications 0.768
0.663 Yes 64 55.2 52 44.8
Yes 8 61.5 5 38.5 No 60 57.1 45 42.9
No 114 55.3 92 44.7 Low¶ cardiometabolic risk 0.332 (1)
Hypertension 2.168 (1) SGA medications 0.564
0.141 Yes 17 51.5 16 48.5
Yes 13 72.2 5 27.8 No 107 56.9 81 43.1
No 109 54.2 92 45.8 Anti-anxiety medications 0.004 (1)
Dyslipidaemia 0.204 (1) 0.947
0.652 Yes 119 55.9 94 44.1
Yes 8 61.5 5 38.5 No 4 57.1 3 42.9
No 113 55.1 92 44.9 Mood stabilizer medications 0.014 (1)
Psychotic disorder 0.121 (1) 0.907
0.727 Yes 30 56.6 23 43.4
Yes 77 57.0 58 43.0 No 23 43.4 74 44.3
No 47 54.7 39 45.3 Antidepressant medications 3.868 (1)
Mood disorder 0.063 (1) 0.049*
0.802 Yes 54 64.3 30 35.7
Yes 44 55.0 36 45.0 No 30 35.7 67 48.3
No 80 56.7 61 43.3 Other* 0.995 (1)
Personality disorder 0.089 (1) 0.319
0.765 Yes 9 69.2 4 30.8
Yes 25 58.1 18 41.9 No 114 55.1 93 44.9
No 99 55.6 79 44.4
Other mental health diagnosis 1.219 (1) *Significant P = <0.05 represents comparison of consumer char-
0.270 acteristic variables and blood pressure completion using Chi-square
Yes 16 66.7 8 33.3 analysis.
No 108 54.8 89 45.2 †Consumers can be included in more than one category due to
Multiple mental health 0.646 (1) dual diagnosis and comorbidities.
diagnoses 0.422 ǂHigh cardiometabolic risk SGA medications include olanzapine
Yes 34 60.7 22 39.3 and clozapine.
No 90 54.5 75 45.5 §Moderate cardiometabolic risk SGA medications include queti-
Antipsychotic medication 0.188 (1) apine, risperidone, paliperidone. SGA – second-generation antipsy-
polypharmacy 0.665 chotic.
Yes 65 57.5 48 42.5 ¶Low cardiometabolic risk SGA medications include lurasidone,
No 59 54.6 49 45.4 asenapine, aripiprazole, ziprasidone, amisulpride.
All antipsychotic medications 0.054 (1) ††Other psychotropic medications include accamprosate,
0.816 buprenorphine, clonidine, methadone, naltrexone, and suboxone.
Yes 110 55.8 87 44.2
No 14 58.3 10 41.7
First-generation antipsychotic 3.872 (1)
diagnoses was similar to reports from previous studies
medications 0.049*
Yes 23 71.9 9 28.1
with most consumers diagnosed with psychotic disor-
No 100 53.2 88 46.8 ders, followed by mood disorders (Brown et al. 2018;
Second-generation 0.030 (1) Millar et al. 2014). The proportions of mental health
antipsychotic medications 0.862 diagnoses were congruent with the literature for con-
Yes 109 55.9 86 44.1 sumer sex. Previous findings showed that people with
No 15 57.7 11 42.3
psychotic disorders were more likely to receive CMM
(Continued) (Millar et al. 2014), though we found no association

© 2020 Australian College of Mental Health Nurses Inc.

8 R. HOWARD ET AL.
between CMM completion and mental health diagnosis
in our study. This is notable because previous literature
has focused on increased cardiometabolic risk in people
with psychotic disorders (Brown, Kim, Mitchell, &
Inskip, 2010; Castle et al. 2017; Galletly et al. 2016; De
Hert et al. 2011; Lambert et al. 2017; Ventriglio et al.
2015) and the only guidance regarding the recom-
mended frequency and nature of CMM is in people
with schizophrenia and related disorders (Galletly et al.
2016).
Risk factors related to lifestyle are often touted as a
leading cause of cardiometabolic comorbidity in mental
health consumers (Holt & Mitchell 2015). Despite this,
staff infrequently assess consumer lifestyle factors such
as diet and physical activity (Behan et al. 2015; Galletly
et al. 2016; Galletly et al. 2012; Holt & Mitchell 2015;
Lambert et al. 2017). The low rate of assessment found
in our study appears to be common; Organ et al.
(2010) reported diet and exercise advice were provided
to less than a quarter of consumers across a public
mental health service even after an intervention to
improve this aspect of care (Organ et al. 2010). Given
these findings, two important issues present them-
selves: First, staff might not document lifestyle assess-
ment and implementation of health promotion
strategies in accordance with their actual practice, a
problem which is supported by reports of widespread
inaccuracy in clinical documentation (Myklebust et al.
2017). Our study for instance, found that over half
(60%) of consumers were prescribed nicotine replace-
ment therapy, yet just over a third (38.6%) of them
had a documented smoking assessment. Therefore, it is
possible that lifestyle assessment and health promotion
took place at higher rates than were documented. Sec-
ond, without initial assessment and accurate evaluation
of risk, consumers may not receive crucial health pro-
motion and support to lead a healthier lifestyle (Organ
et al. 2010). Consumers may not be given highly valu-
able strategies and information that could empower
them to effect positive change upon their health out-
comes (Behan et al. 2015).
Antipsychotic medication polypharmacy occurred in
over half (52.2%) of consumers in this study. Prescrip-
tion of more than a single antipsychotic medication is
contrary to the RANZCP guidelines in the treatment of
psychotic disorders (Galletly et al. 2016) and mood dis-
orders (Malhi et al. 2015), though it is recognized this
may be required in some circumstances. In our study,
antipsychotic medications were prescribed to the vast
majority (89.5%) of consumers across all mental health
diagnoses. This finding supports the need for
comprehensive CMM for all mental health IPU con-
sumers, regardless of diagnoses (Vancampfort et al.
2015). Prescription of SGA medications is associated
with sudden cardiac death through QT prolongation
and torsades de pointes (Manchia et al. 2017) and pose
significant cardiometabolic risk (Stahl 2008). While
88.6% (n = 202) of consumers were prescribed SGA
medication in the current study, electrocardiographs
were completed for just over half (53.7%) of them. The
inverse association between low CMM rates and high
frequencies of SGA prescription demonstrates a failure
to stratify and prioritize cardiometabolic risk accord-
ingly, contravening evidence-based practice (Happell
et al. 2012; Stahl 2008; Wynaden et al. 2016).
Alignment of IPU staff practices with accepted
Australian standards of best practice
A major finding of this study was the sporadic nature of
CMM, confirming previous reports of ad hoc assess-
ment (Happell et al. 2016; Millar et al. 2014). Statisti-
cally significant associations were found between CMM
completion and FGA medication prescription, antide-
pressant prescription, and site of inpatient admission,
demonstrating suboptimal and inconsistent awareness
of cardiometabolic risk. The finding that CMM comple-
tion was significantly associated with site of admission
across a single health service suggests that IPU culture
and staff mix influenced the rate of CMM and physical
health assessment. Numerous authors report that higher
levels of service support and educational interventions
are effective in facilitating increased rates of CMM and
physical health assessment in the short term (Hetrick
et al. 2010; Organ et al. 2010; Parrinello 2012).
The RANZCP clinical practice guideline for the
management of schizophrenia and related disorders
(Galletly et al. 2016), local practice guidelines, and the
work by Millar et al. (2014) formed the basis of
accepted standards of CMM and physical health assess-
ment practice at the time of this study. The RANZCP’s
guideline recommends taking a consumer’s health his-
tory, including identification of modifiable and non-
modifiable risk factors, pathology tests such as a fasting
lipid profiles, fasting plasma glucose levels, haemoglo-
bin A1c measurements, electrocardiography, height,
weight, body mass index, and waist circumference at
baseline and subsequent time intervals (Galletly et al.
2016). The local health service practice guideline direc-
ted staff to undertake a comprehensive physical health
assessment, including a history of chronic disease and
comorbidities within two hours of consumer admission
© 2020 Australian College of Mental Health Nurses Inc.
PHYSICAL HEALTH AND CMM IN THREE INPATIENT UNITS
to an IPU. The local practice guideline also stipulated
that nursing staff were to measure height and weight
upon admission and to take a minimum of daily physio-
logical observations, including blood pressure, heart
rate, respiratory rate, oxygen saturation, and tempera-
ture. According to our findings, this sample of mental
health consumers did not receive CMM and physical
health assessment within the first 72 hours of admis-
sion to a mental health IPU in line with best practice
standards.
Barriers to evidence-based CMM
Multiple service- and consumer-related barriers
impede the delivery of CMM (Mitchell et al. 2012).
Service-related barriers are encountered where there
are low levels of organizational and cultural support for
guideline recommended CMM practices (Velligan et al.
2013). The absence of equipment required to complete
CMM was also identified as a barrier (Hetrick et al.
2010), as were low levels of clinician motivation
(Okkels et al. 2013). Time constraints and excessive
nursing workloads were important structural issues
(Brown et al. 2018). Additionally, poor integration
between primary health and specialized mental health
services was reported to effect delegation of responsi-
bility for CMM and follow-up post discharge (Laugh-
arne et al. 2016; Organ et al. 2010).
Regarding consumer-related barriers to CMM,
symptom severity, difficulty expressing physical health
concerns and low adherence to treatment hinder health
professionals’ efforts to provide comprehensive physical
health care (Organ et al. 2010). Some staff have
reported a misconception that consumers are not inter-
ested in their physical health (Rosenbaum et al. 2014;
Wynaden et al. 2016); however, this assumption is
argued to be stigmatizing and baseless (Wynaden et al.
2016). In our study, very few consumers declined
CMM. Likewise, Brown et al. (2018) found that in the
most acute phases of SMI, rates of declined CMM
were low (Brown et al. 2018). Other studies of attitudes
towards waist circumference concur that consumers
rarely declined measurement (Rosenbaum et al. 2014;
Stanton et al. 2017). In contrast to reports of disinter-
est in physical health, mental health consumers want to
take ownership over their physical health and are enti-
tled to appropriate information and support to enable
them to do so (Australian Government National Mental
Health Commission 2016; Organ et al. 2010).
Peer support workers are members of the mental
health workforce who use their own lived experience of
© 2020 Australian College of Mental Health Nurses Inc.
9
mental illness to support consumers (Bocking et al.
2018). Thus far, the focus of peer support worker roles
in the Australian context has been to support con-
sumers to manage their mental health (Bocking et al.
2018). Peer support worker roles that support a holistic
view of mental and physical health are increasingly
being explored and endorsed in Australian policy
(Bocking et al. 2018; Stubbs et al. 2016). Peer support
models for people with chronic diseases have been
implemented in the past with positive effects across
multiple physical health parameters, though the evi-
dence-base regarding the effect of peer support inter-
ventions for people with concurrent mental and
physical health concerns is currently lacking (Stubbs
et al. 2016). Qualitative studies have shown high levels
of support from consumers (Bocking et al. 2018; Stan-
hope & Henwood 2014). There is great potential to
better engage and empower consumers in a holistic
approach to health with peer support that can facilitate
access and navigation of the broader health system
(Stanhope & Henwood 2014). Importantly, the success
of peer support interventions depends on high levels of
organizational support to facilitate change and build
new models into pre-existing culture and structures
(Stubbs et al. 2016).
Strengths and limitations
Globally, the evidence-based guidance surrounding
CMM and physical health assessment of mental health
consumers lacks universal agreement (Batscha et al.
2010; Brown et al. 2018; Millar et al. 2014; Vancamp-
fort et al. 2015). Therefore, a major strength of this
study was the use of a pre-validated audit tool (Millar
et al. 2014) in conjunction with the RANZCP’s guide-
line for the management of schizophrenia and related
disorders (Galletly et al. 2016) and local policy.
The use of retrospective medical record audit
method is associated with some well-recognized limita-
tions (Gregory & Radovinsky 2012). Medical records
may be incomplete or inaccurate and of variable qual-
ity, resulting in difficulties collecting and interpreting
data (Gregory & Radovinsky 2012; Myklebust et al.
2017). However, the reliability and validity of the audit
tool was founded in a pre-validated audit tool, reliable
literature and policy, and expert opinion from a panel
of experienced clinicians, which mitigated these limita-
tions (Polit & Beck 2010). The variables collected by
the audit tool were pre-determined by the research
team, resulting in the risk that the phenomenon was
not captured in full. Medical record audits have been
10
previously shown to increase the frequency of physical
health assessment in people with SMI and encourage
organizational change (Pitman et al. 2011). Medical
record audit research design encourages quality
improvement and practical and locally relevant inter-
ventions using broad recommendations to identify gaps
in service delivery (Organ et al. 2010; Pitman et al.
2011). The use of medical record audit in this study
aimed to foster a similar effect within the current IPU
setting, with the option to further examine this CMM
practices in the future.
Limiting the investigation to consumers’ first
72 hours of admission was deemed appropriate by the
research team, organizational policy, and an expert
advisory panel. Previous research supports that CMM
usually occurs early in an admission to a mental health
IPU with rates of CMM likely to decline thereafter
(Batscha et al. 2010). However, it is acknowledged that
CMM and physical health assessment may occur in
varying rates during a consumers’ admission due to
competing IPU priorities and consumer-related exigen-
cies.
The mechanisms described to ensure rigour
included a randomly selected, sufficiently powered
sample size, and triangulation of data collected from
consumer medical records (Naing et al. 2006; Polit &
Beck 2010). While triangulation of the data enhances
rigour (Polit & Beck 2010), the multiple data sources
and the depth of searching required to collect CMM
and physical health assessment data from the medical
records indicate that clinicians would struggle to locate
sufficient information to apply it in clinical practice
(Millar et al. 2014; Wynaden et al. 2016). Sampling
from one organization also reduced the study’s general-
izability to other services (Polit & Beck 2010); however,
external validity was enhanced through inclusion of
three separate IPUs across multiple sites at a large
metropolitan health service.
Implications for practice
Multiple authors have commented on the likely failure
of clinical practice guidelines in isolation to achieve
rates of CMM required to address the disproportionate
cardiometabolic risk for mental health consumers on a
local level (Behan et al. 2015; De Hert et al. 2010;
Mitchell et al. 2012; Velligan et al. 2013). Successful
implementation of clinical practice guidelines requires
concerted targeting of local systems and delegation of
professional responsibility for guideline adherence,
while reinforcing local organizational support and
R. HOWARD ET AL.
structures (Lambert et al. 2017; Okkels et al. 2013; Par-
rinello 2012; Velligan et al. 2013). For example, previ-
ous studies have advocated for structural or system-
level interventions, including programming reminder
software for CMM (Brunero & Lamont 2009; Velligan
et al. 2013). Staff buy-in and education has been shown
to be effective in promoting and maintaining best prac-
tice in clinical settings (Organ et al. 2010; Parrinello
2012). It is frequently reported that many mental
health professionals do not feel confident in providing
CMM and physical health assessment to consumers
(Behan et al. 2015; Happell, Scott, Nankivell, & Plata-
nia-Phung, 2013; Laugharne et al. 2016; Stanton et al.
2016). Two recent studies have examined the effect of
nurse practitioner roles dedicated to conducting CMM
and making referrals based on findings in inpatient and
community mental health settings (Brown et al. 2018;
Furness et al. 2020). These studies have shown positive
results in both increasing rates of CMM and providing
clinical leadership within the settings, making CMM
more visible to other staff (Brown et al. 2018; Furness
et al. 2020).
CONCLUSION
This study contributes to a wider body of evidence
examining the quality of physical health assessment for
consumers of mental health services. It provides base-
line data and serves as an opportunity for healthcare
organizations providing care to mental health con-
sumers to evaluate practices in CMM and physical
health assessment in the IPU setting, of which there is
little available literature (NHMRC 2009). Our study
highlights the need to develop locally relevant guideli-
nes congruent with evidence-based practice and Aus-
tralian policy, and active dissemination among staff to
promote higher rates of CMM and physical health
assessment in the first instance. Future design and
evaluation of interventions aiming to improve current
practices within the inpatient setting are needed. Peer
support worker roles and programmes targeted at sup-
porting people with concurrent mental and physical
health concerns; and the emergence of nurse practi-
tioner roles dedicated to CMM and physical health
assessment for consumers are promising interventions
worthy of further exploration.
ACKNOWLEDGEMENTS
The authors acknowledge the support of Dr Moham-
madreza Mohebbi, Senior research fellow, Biostatistics
© 2020 Australian College of Mental Health Nurses Inc.
PHYSICAL HEALTH AND CMM IN THREE INPATIENT UNITS
Unit, Faculty of Health, Deakin University and Eastern
Health Decision Support Services in completing this
work.
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