J Psychiatr Ment Health Nurs. 2019;00:1–15. wileyonlinelibrary.com/journal/jpm  | 1© 2019 John Wiley & Sons Ltd

Received:11July2018  |  Revised:6July2019  |  Accepted:26July2019DOI: 10.1111/jpm.12553

O R I G I N A L A R T I C L E

Initial psychometric evaluation of the physical health attitude scale and a survey of mental health nurses

Zeynep Özaslan1  | Hülya Bilgin2  | Suna Uysal Yalçın3  | Mark Haddad4

Thisstudywaspresentedasanoralpaperin5thEuropeanConferenceonMentalHealthinPrague,CzechRepublic,2016.

1IstinyeUniversity,İstanbul,Turkey2IstanbulUniversity‐Cerrahpaşa,İstanbul,Turkey3KocaeliUniversity,Kocaeli,Turkey4CityUniversityofLondon,London,UK

CorrespondenceZeynepÖzaslan,HealthScienceFaculty,IstinyeUniversity,İstanbul,Turkey.Email:zznp@hotmail.com

Accessible summaryWhat is known on the subject?• Aclearassociationexistsbetweenseriousmentalillness(SMI)andpoorphysicalhealth.

• IndividualswithSMIhavemarkedlyhigherrisksformortalityandmorbidity.• Mentalhealthnursesplayan importantrole inenhancingserviceusers'mentalandphysicalwell‐being.

• The attitudes ofmental health nurses towards physical health care have beenexplored in thewesternpartof theworld.However, cross‐countrydifferencesshouldbedeterminedtorevealtheimportanceofthisglobalissue.

What the paper adds to existing knowledge?• ThisstudyaddsnewdatatotheliteratureonthePhysicalHealthAttitudeScale's(PHASe)validityandnurses'attitudeswhenworkinginacutementalhealthser‐vicesindifferentcultures.

• Nursesinacutementalhealthwardsmostlyfocusonthebasicphysiologicalindi‐catorsofpatients'existingphysicalhealthproblems,sohealthpromotionpracticessuchassexualhealthandeye/dentalexaminationsareneglectedforindividualswithSMI.

• Nurses'higherlevelofconfidenceabouttheirdeliveryofphysicalhealthcareisduetotheirfamiliaritywithbasicnursingpractices(e.g.monitoringbloodpressureandcheckingbloodglucoselevels).

• Differencesthatexistbetweencountriesinrelationtosmokinghabitsareprob‐ablyduetodifferentregulations.

What are the implications for practice?• To improve patients' physical healthcare outcomes, nurses should be providedwithadditionaltrainingandsupervisiontostrengthentheirskillsandconfidence.

• Nurses'perceivedneedforadditionaltrainingreflectstheimportanceofphysicalhealthcareinmentalhealthsettings,inwhichtrainingcouldsubstantiallyimprovepatientoutcomes.

• Authorsbelievethatstandardprotocolsmustbeestablishedinacutepsychiatriccaretoeliminateobstaclestoholisticpatientcare.

2  |     ÖZASLAN et AL.

1  | INTRODUC TION

Aclearassociationexistsbetweenmentalillnessandpoorphysicalhealth(Tylee&Haddad,2007).Researchershavereportedthatindi‐vidualswithseriousmentalillness(SMI)experiencemarkedlyhigherlevelsofriskformedicalmorbiditiesanddiminishedlifeexpectancy,whichistypicallyreducedbyaround15years(Chesney,Goodwin,&Fazel,2014).Populationstudiesshowthatcirculatorydiseasesandcancerare themaincausesofprematuremortality in thispopula‐tion, accounting for between 77% and 90%of all deaths (Crump,Winkleby,Sundquist,&Sundquist,2013;Jayatillekeetal.,2017).

TheexcessiveprevalenceofphysicalhealthconditionsevidentamongpeoplewithSMIappears tobedue toacomplex interplayof factors, includingmarkedlyhigher ratesofsubstanceabuse, in‐cluding tobacco (Royal College of Physicians & Royal College ofPsychiatrists,2013),alcoholandillicitdrugs.Thehighincidenceofunhealthy lifestyles, such as poor diets and insufficient exercise

(Osborn,Nazareth,&King,2007),andthesideeffectsofpsychotro‐picmedication(DeHert,Detraux,VanWinkel,Yu,&Correll,2012)alsoaffectindividualswithSMI.Eachoftheseproblemsshouldbeassessedandmanagedbyhealthprofessionals.

Thispopulation'sheightenedriskofdevelopingphysicalhealthproblemshasaseriousimpactonpatients'abilitytofunction,qualityoflifeandlifeexpectancy.Nonetheless,reviewsandmeta‐analysesconducted indiversesettingsclearly showthatmanypatientsareneitherroutinelyscreenednormonitoredforphysicalcomorbidities(Mitchell,Delaffon,Vancampfort,Correll,&DeHert,2012;Mitchell,Malone,&Doebbeling,2009;RoyalCollegeofPsychiatrists,2014).Theseindividualsalsodonotreceiveadequatehealthpromotionandsupport for lifestyle changes (Mitchell, Vancampfort, De Hert, &Stubbs,2015).

TheneedtoaddressphysicalhealthinequalitiesinpeoplewithSMIisclear.Initiativeshaveincludedincentives(Kontopantelisetal.,2015)and trainingprogrammes (Hardy,2012) thathavesought to

• Trainingneedsofmentalhealthnursesonhealthpromotionpracticesshouldbeconsideredbyadministratorsofmentalhealthsettings.

AbstractIntroduction: Nursesplayanimportantroleinimprovingthephysicalhealthofindi‐vidualswithseriousmentalillnesses.Theliteratureontheattitudesofmentalhealthnursestowardsphysicalhealthcareprovidesasmallamountofdata.Assessingtrendsinnurses'attitudesthroughsuitablesurveysisimportanttoensureholisticcare.Aim/Question: This study sought to examine the Turkish version of the PhysicalHealthAttitudeScale's(PHASe)validityandreliabilityandtosurveyTurkishmentalhealthnurses'attitudestowardsphysicalhealthcare.Method: The sample consisted of 174 nursesworking in acute psychiatricwards.Firstly,thepsychometricpropertiesofthescalewereanalysedusingfactoranalysisandmeasuresofinternalconsistencyandreliability.Then,thesurveyresultsoftheattitudesofmentalhealthnursestowardsthephysicalhealthofpatientswithseriousmentalillnessesweredeterminedusingthePhysicalHealthAttitudeScale(PHASe).Results: The translated PHASe functioned best as a 24‐item version and 4‐factorsolutionthatexplains51.3%ofthevariance.Theinternalconsistencyvaluewas0.83.Therespondents'attitudesweregenerallypositiveabouttheirrole.Therewaslessagreementforthe involvementofnurses inpracticesofhealthpromotion,suchassexualhealth,eyeand/ordentalexaminations.Thenursessurveyedalsotendedtousesmokingfortherapeuticpurposes.Implications for practice: Mentalhealthnurses'knowledgeandattitudesshouldbeenhanced by additional training in the ways of meeting patients' biopsychosocialneeds.Obstaclestophysicalhealthcarecanberemovedbyimplementingstandardprotocolsnationwide.

K E Y W O R D S

attitude,deliveryofhealthcare,health,mentalhealth,nurses,patients,surveysandquestionnaires,validityandreliability

     |  3ÖZASLAN et AL.

improveprimary andmedical care for these individuals.However,researchershaveidentifiedvariousobstaclestooptimalcareinthiscontext. These include limitations in knowledge and confidence(McBain et al., 2016), role ambiguities (Happell, Platania‐Phung,&Scott,2014)andoverlycomplexpresentations(Shefer,Henderson,Howard,Murray,&Thornicroft,2014).

Until recently, little attention has been paid to mental healthnurses' role in and potential for addressing this major health dis‐parity.Issuesrelatedtothesenurses'adequatetraininginphysicalhealthneedshavebeenidentifiedbysurveysconductedininpatientsettings(Howard&Gamble,2011).Respondentshavealsoincludedcommunity‐basednursesintheUnitedKingdom(UK)(Nash,2005)andAustralia(Happell,Stanton,Hoey,&Scott,2014).

Surveystogetherwithresearchbasedoninterviewsandfocusgroups (Dunbar, Brandt, Wheeler, & Harrison, 2010; Happell,Scott, Nankivell, & Platania‐Phung, 2013) have explored nurses'attitudes towards physical care, aswell as their concerns abouttheir knowledge and role. The results have revealed divergentviews among themental health nurses surveyed,who generallyacknowledge the importance of physical health care and of thepartnursesshouldplayinthis.However,thefindingsincludevari‐abilityintheseprofessionals'confidenceintheirabilitytomonitorandpromotepatients'physicalhealth(Happell,Platania‐Phung,etal., 2014;Morrison,Mechan,&Stomski, 2015;Robson,Haddad,Gray, & Gournay, 2013). Some studies have demonstrated thathealthcare professionals have positive attitudes (Bartlem et al.,2016; Robson, Cole, et al., 2013;Wye et al., 2010),while otherresearchhasfoundtheopposite (Hyland,Judd,Davidson,Jolley,&Hocking, 2003). The attitudes and existing barriers of nursesrestrainpatients fromtaking thenecessaryphysicalhealthcare.Therefore,itisimportanttoseektheviewsofnursestoimprovepatientcareandto increase thequalityofcare.Althoughphysi‐calcareisanimportantpartoftherolesofnurses,theliteraturestillprovidesasmallamountofdataontheirviews(Bressingtonetal.,2018;Çelikİnce,PartlakGünüşen,&Serçe,2018;Ganiah,Al‐Hussami,&Alhadidi,2017;Happell,Stanton,etal.,2014;Robson,Haddad,etal.,2013;Siren,Cleverley,Strudwick,&Brennenstuhl,2018).

Mental health services in Turkey are mainly provided by thepublic sector, followinghospital‐basedmodels.Eight regionswerepreviouslyaffiliatedwiththeMinistryofHealth,providingservicestowidegeographical areasand largepopulations. In2011,Turkeywasdivided into29regionsbytheMinistryofHealth inareorga‐nizationofallhealthcareservices, includingpatientbeds.Thegoalwastoreducethenumberofbedsandspreadthemacrossthecoun‐try.Simultaneously,thereformstriedtochangethehealthsystemto a community‐hospital balancemodel by increasing the numberofcommunitymentalhealthcentres.Currently,thesystemincludesapproximately 170 community mental health centres. In hospi‐tal‐basedpractice, thedurationofhospitalization inacuteunits isapproximately 2 weeks. Blood pressure measurements and fol‐low‐upofweightcontrolareimportantnursingactivitieswithintheareaofphysicalhealthneedsduringcareperiodsforpatientsusing

psychiatricservices.Otherphysicalhealthassessments(e.g.diabe‐tes,cardiacdisease,dentalandgynaecologicalexaminations)canbemade as needed. In addition, patients are encouraged to exercisewhileinacutewards(Alataş,Kahiloğulları,&Yanık,2011).Whenthepatientishospitalizedforacuteconditions,mentalhealthcareoftenfaroverweighsphysicalcare.Inpatientcareinacutepsychiatricunitsthusinvolvesbasictreatmentsandhealthcare,duetoincreasedriskforadverseeffectsrelatedtomedicationandpoorlivingconditions.Holisticcareincludingphysicalhealthassessment,planningofcareandhealtheducationshouldbehandledinthescopeoftheknowl‐edge,skillsandrolesofthenurse.NursingdegreesinTurkeypreparegraduatesforgenericnursingjobs.Althoughprogrammesemphasizeholistic nursing care, this approach is still neglected in psychiatricinstitutions.Nursesneed touse their competencies in this crucialareatoensurepracticesthatwillimprovephysicalhealthcaresincetheseprofessionalsaredirectlyinvolvedinpatientcare.Knowledge,skills,attitudesandvaluesplayaroleinwideningthescopeofcom‐petencies (Fukada, 2018). Thus, priority should be given to deter‐miningwhichattitudesincreasementalhealthnurses'competenceandtranslationofknowledgeintopractice.

Various studies have explored the involvement of mentalhealthprofessionalsinandattitudetowardsphysicalhealthcareinAsiancountries(Bressingtonetal.,2018),UK(Howard&Gamble,2011;Robson,Haddad,etal.,2013),Jordan(Ganiahetal.,2017),Turkey(Çelikİnceetal.,2018)andCanada(Sirenetal.,2018).Theattitudesofmentalhealthnursestowardsandpracticeofphysi‐calhealthcareforpatientswithSMIshaverarelybeenstudiedinTurkey.Arecentlypublishedqualitativestudyinvolving12nursesappears to be the only research onmental health nurses' opin‐ionsaboutphysicalhealthcareinTurkey(Çelikİnceetal.,2018).However,therearestillnoquantitativedatatoimprovethephys‐icalhealthandneedsofpsychiatricpatientsthatcanbereferred.There is also no standardized measurement tool to obtain thisdata.

Tothebestofourknowledge,thereisonlyonecommonlyusedscale in the international literature that determines the attitudesofnursesregardingphysicalhealth inpsychiatriccare (Sirenetal.,2018).ThePhysicalHealthAttitudeScale(PHASe)isameasurementtool that provides a fuller understanding ofmental health nurses'attitudestowardspsychiatricpatients'physicalhealthcare(Robson&Haddad,2012). This scale reflects themulti‐dimensional natureofmentalhealthnurses'participationinphysicalhealthcare,confi‐dencewhileprovidingcare,perceivedbarriersandattitudestowardssmoking.Tothisend, thePHASewasusedtoevaluatetheoveralltendenciesofnurses'attitudestowardsthephysicalhealthofindi‐vidualswithSMIinTurkey'slargestpsychiatrichospital,whichwasconsideredrepresentativeofthestudypopulationintermsofqualityandquantity.

Therationaleforthisresearch'suseofastandardizedinstrumentwas the urgent need to determine and quantify the key variablesrelated to mental health nurses' attitudes. The PHASe's psycho‐metric properties had been previously assessed by Robson andHaddad (2012) in a different setting from that inwhich the scale

4  |     ÖZASLAN et AL.

wasdeveloped,whichprovidedadditionalevidenceofitsreliabilityindifferentculturalcontexts.

2  | METHODS

Thisresearch'sresultswerecompiledbyfollowingtheSTrengtheningtheReportingofOBservationalstudies inEpidemiology (STROBE;Appendix1)guidelines(VonElmetal.,2007).

2.1 | Aim

The present study sought to examine the Turkish version of thePhysicalHealthAttitudeScale's(PHASe)validityandreliabilityandtosurveyTurkishmentalhealthnurses'attitudestowardsphysicalhealthcare.

2.2 | Study design, setting and participants

Thecurrentstudyhadacross‐sectionaldesign.ItwasconductedintheMentalHealthandNeurologicalDiseasesTrainingandResearchHospital affiliatedwith theMinistry ofHealth in Istanbul, Turkey.All the registered nurses working in this hospital were invited toparticipateinthesurveyinface‐to‐faceinterviews.Hardcopiesofthequestionnaireweredistributedtothenurseswhoacceptedtheinvitationtoparticipate,sonorandomsampleselectionmethodwasapplied.

Mentalhealthnurses'traininginTurkeyissimilartothatoftheUnited States (US), Australia and most European nations, start‐ingwitha4‐yeargenericregisterednurseprogramme.Thenursesworking inmentalhealth‐relatedservices ideallyalsohavefurtherspecialist postgraduate education, but generically qualifiednursescanalsotakeontheserolesandreceivein‐servicetraining.Thedatawere collected between September 2015 and September 2016.A remindermessagewas sent to respondents, as needed, once amonththroughtheheadnurseofunits.

2.3 | Measure

ThePHASe is a tool developed tomeasuremental health nurses'attitudesabouttheirinvolvementinphysicalhealthcare(Robson&Haddad,2012).This28‐itemscalewasbasedonaliteraturereview,focusgroupsmadeupofstaffandserviceusersandprincipalcompo‐nentanalysis(PCA)ofnurses'responsestothedraftquestionnaire(Robson&Haddad, 2012). The PHASe is a self‐report instrumentcomprisedof four sub‐scales: (a)attitudes towards involvement inphysicalhealthcare(10items),(b)confidenceindeliveringphysicalhealthcare(six items), (c)perceivedbarrierstophysicalhealthcaredelivery(sevenitems)and(d)attitudestowardssmoking(fiveitems).All items are scored on a 5‐point Likert scale (1 = “Strongly disa‐gree”;5= “Stronglyagree”),andscoring is reversed fornegativelywordeditemssothathigherscoresindicatemorepositiveattitudes.Theinternalconsistency(i.e.Cronbach'salpha)withintheUKtesting

samplewas0.76forthetotalscale.Forsub‐scale1,thevalueob‐tainedwas0.86, for sub‐scale 2, 0.74, sub‐scale 3, 0.67 and sub‐scale4,0.61.

Questions on demographic characteristics focused on age,gender,education,durationofworkexperience inmentalhealthand smoking status. Further items assessed whether respon‐dentshadeverhadin‐servicephysicalhealthcaretrainingacrossa range of areas (e.g. diabetesmanagement, smoking cessation,cardiometabolichealth,exerciseandnutrition).Nurseswerealsoaskedwhethertheir roleprior toworking inthepsychiatrichos‐pital predominantly involved physical health care (e.g. generalhospital or medical settings). The questions related to involve‐ment, in general, in and specific aspects of physical healthcarepracticewerescoredonaLikertscalerangingfrom1(“Never”)to5 (“Always”),whileperceived trainingneedswere ratedas “Yes”,“No”or“Unsure”.

2.4 | Ethical approval

The study was approved by human research ethics committee(01.09.2015, Project Reference Number: 487). Nurses were firstgiven information about the research's details, and the respond‐entsthengavetheirverbalandwrittenconsent.Participationwasentirelyonavoluntarybasis.Respondentswerealsoinformedthattheycouldcontacttheresearchteamatanytimeforquestionsortodiscussthestudy.

2.5 | Translation procedure

The translation process comprised the following steps based onBrislin's (1970) translation model. First, the scale was forwardtranslated fromEnglish intoTurkishbyabilingualexpert. Second,a different bilingual expert blindly back‐translated the scale fromthe Turkish version into English. Third, the twoEnglish versions—theoriginal and theback‐translated—were compared for semanticequivalence.Minordifferencesweredetectedintheback‐translatedversionwhenitwascomparedtotheoriginal.Last,thesedifferencesinthescalewerecorrectedbybilingualexperts(Brislin,1970).

Thescale'sfinalversionwassenttothenativeauthor.Aftermak‐ingminorchangesproposedbytheauthor,thebilingualexpertswereaskedtoreviewthescaleagain,andthisversionwasacceptedastheofficialversion.Twomentalhealthnursingacademicsand10mentalhealthnursesevaluatedthisversionintermsofclarityandintelligi‐bility.ThefinalTurkishversion'scontentvaliditywasconfirmedbyapilotstudywith20mentalhealthnursesattheselectedhospital.Thedatafromthepilotstudywerenotincludedintheanalysisasthepur‐poseofconductingthiswaspurelytoexaminethescale'sfeasibility.

2.6 | Sample size calculation

Oneofthemethodsoftenusedtocalculatetheappropriatesam‐plesizeforfactoranalysisofameasurementinstrumentistore‐cruitbetween5and10respondentsperitem(Tabachnick&Fidell,

     |  5ÖZASLAN et AL.

2013). The original instrument comprised 28 items, so a samplesizeofbetween140and280wasneeded.Theavailableconveni‐encesample'ssize(i.e.allmentalhealthnursesworkinginthehos‐pital)was230,whichmeantthatallthesenurseswereinvitedtoparticipate.

2.7 | Data analysis

The data were analysed using both Number Cruncher StatisticalSystem 2007 and IBM Statistical Package for the Social SciencesStatistics for Windows version 23 software. Descriptive statis‐tics (i.e.mean,standarddeviation[SD], frequencyandpercentage)wereusedtodescribethesample'scharacteristicsandnurses'cur‐rent practices, perceived training needs, attitudes and confidenceasmeasured by PHASe items. The Turkish PHASe's psychometricpropertieswere analysedusing exploratory and confirmatory fac‐toranalysis(EFA,CFA),whichincludedorthogonal(i.e.varimax)ro‐tation. Itemswitha factor loading lower than0.30wereexcludedfromfurtheranalyses(Tabachnick&Fidell,2013).Significancewasassessedatp < .05 level.

In addition, the Kaiser–Meyer–Olkin (KMO) proficiency mea‐surementandBartlett'ssphericitytestwereusedtomeasuresuit‐abilityforfactoranalysis.Cronbach'salphawasutilizedtoexamineinternalconsistency,and item‐totalcorrelationswereexamined todetermine item relevance or redundancy in the overall scale. ForPHASe, intraclass correlation coefficient (ICC) was calculated fortest–retestreliability(95%confidenceintervals).

3  | RESULTS

3.1 | Participants

Atthetimeofthepresentresearch,230registerednursesworkedatthehospital.Thefirstphase(i.e.thepilotstudy)wascompletedwith20nursesrandomlyselectedoutofthestudypopulation.Ofthe210nursesaskedtoparticipate,174(83%)responded.Thefirst15respondents'initialandfollow‐upratingswereusedtoexaminethescale'stest–retestreliability.

Thenurses'mean agewas34 years (SD = 0.54; seeTable1),three‐quarterswerefemale(75.9%),nearlyhalfhadadegree‐leveleducation,while119(68.4%)hadworkedinnonpsychiatricsettingsprior to their current post. The average duration of the respon‐dents'careerinmentalhealthwas7.3years(SD=0.52),and42%ofnurseswerecurrentsmokers(50%ofmalesand39%offemales).Almostallhadpreviouslyreceivedphysicalhealthcaretraining.

3.2 | Current practice

The respondents reported thatmaking initial assessments,moni‐toring blood pressure and/or glucose and helping with personalhygienewerethemostcommonphysicalhealthcarepractices(seeTable1above).Ensuringregulareyeexaminationsandpatients'reg‐istrationwithfamilymedicalpractitionersweretheleastfrequentactivities.

3.3 | Perceived training needs

Therespondentsnotedthattheyneedmoretrainingonarangeoftopics. Assisting patients in managing their cardiovascular health

TA B L E 1  Samplecharacteristics(n=174)

Variable n %

Gender

Female 132 75.9

Male 42 24.1

Educationalbackground

HighSchool 16 9.2

Two‐yearDegree 34 19.5

Degree(baccalaureate) 85 48.9

Postgraduate 39 22.4

Smoking

Yes 73 42

No 101 58

Undertakenin‐servicephysicalhealthcaretraining

Yes 160 92

No 14 8

Workinginphysicalhealthcarepriortocurrentpostsinmentalhealthcare

Yes 119 68.4

No 55 31.6

M SD

Age 34 0.54

Theaveragedurationofcareerinmen‐talhealth(year)

7.3 0.52

Current practices

No. of staff frequently involved (always/very often)

Monitoringclients'bloodpressure 164 94.3

Assessingphysicalhealthconditionofpatientsonadmission

157 90.2

Helpingclients'personalhygienewherenecessary

152 87.4

Checkingbloodglucoselevel 143 82.2

Encouragingclientstoeathealthily 140 80.5

Assessingclients'bowelhabits 129 74.1

Checkingclients'weightregularly 128 73.6

Helpingclientsmanagetheirweight 121 69.5

Encouragingclientstoexerciseregularly

120 69.0

Checkingiftheclientsareregisteredwithfamilyhealthcentre

53 30.5

Ensuringclientshavetheireyechecks.

42 24.1

Abbreviations:%,percentages;M,mean;n,frequency;SD,standarddeviation.

6  |     ÖZASLAN et AL.

TA B L E 2  Factoranalysismatrix(24items)

Items

Factors Initial eigenvalues

1 2 3 4 Total % of Variance

22Ensuringclientshavetheireyesregularlycheckedbyanopticianshouldbepartofthementalhealthnurses'role

0.846 0.042 0.089 0.198 5.55 23.12

17Mentalhealthnursesshouldeducatefemaleclientsabouttheimpor‐tanceofbreastself‐examination

0.799 0.080 0.084 −0.031

25Mentalhealthnursesshouldeducatemaleclientsabouttheimpor‐tanceoftesticularself‐examination

0.767 0.004 0.037 0.264

10Ensuringclientsareregisteredwithadentistshouldbepartofthementalhealthnurses'role

0.765 0.100 0.015 0.108

6Givingadviceonhowtopreventheartdiseaseshouldbepartofthementalhealthnurses'role

0.707 0.309 0.143 −0.099

11Mentalhealthnursesshouldprovideclientswithcontraceptiveadvice

0.697 0.211 0.019 −0.165

1Helpingclientsmanagetheirweightshouldbepartofthementalhealthnurses'role

0.464 0.521 0.199 −0.222

2Givingnutritionaladvicetoclientsshouldbepartofamentalhealthnursesrole

0.443 0.498 0.292 −0.263

19IamconfidentthatIwouldknowifaclientwaspresentingwithsymptomsofhypoglycaemia

0.028 0.769 0.104 −0.109 3.04 12.67

26IamconfidentthatIcouldresuscitateaclientwhohadacardiacarrest

−0.096 0.692 −0.140 0.107

3IamconfidentthatIwouldknowifsomeonewaspresentingwithsymptomsofhyperglycaemia

0.090 0.653 0.222 −0.298

21IamconfidentthatIknowwhichpsychotropicdrugsincreasetheriskthataclientmayexperiencecardiacproblems

0.278 0.612 −0.237 0.195

8IamconfidentthatIcanmeasureaclients'blood‐pressureaccurately 0.165 0.593 0.167 −0.193

9Itisdifficulttogetclientstofollowadviceonhowtomanagetheirweight

−0.016 0.037 0.728 0.025 2.06 8.56

18Itisdifficulttogetclientstofollowhealthy‐eatingadvice −0.055 0.190 0.691 −0.156

15.Clientsarenotmotivatedtoexercise 0.034 0.339 0.489 0.030

5Clientswithseriousmentalhealthproblemsarenotinterestedinimprovingtheirphysicalhealth

0.014 0.011 0.470 −0.086

23Myworkloadpreventsmedoinganyphysicalhealthpromotionwithclients

0.166 0.261 0.436 −0.062

28Staffandclientssmokingtogetherhelpstobuildatherapeuticrelationship

0.011 0.302 −0.064 0.765 1.66 6.90

16Clientsshouldbegivencigarettestohelpachievetherapeuticgoals −0.037 0.097 0.076 0.714

12Clientsshouldnotbeencouragedtogiveupsmoking,astheyhaveenoughtocopewith

0.322 0.079 −0.091 0.535

13Informingclientsaboutthepossibleeffectsofmedicationmayhaveontheirphysicalhealthwillincreasenon‐adherence

0.110 0.317 −0.009 0.527

27Clients'physicalhealthworriesaremostlyduetotheirmentalillness 0.161 0.108 0.034 0.454

7Itshouldnotbethementalhealthnurseroletocheckwithaclientiftheyhavehadcancerscreeningchecks(i.e.cervicalsmearandmammogram)

0.322 0.079 −0.091 0.368

Note: BoldvaluesareindicatetomaketheitemsthatconstitutethefactorsvisiblecollectivelyFourfactorsexplain51.3%ofthevarianceofthetranslatedPHASe.Extractionmethod:Principalcomponentanalysis.Rotationmethod:VarimaxwithKaisernormalization.Factor1:Nurses’attitudestoinvolvementinphysicalhealthcare(8items).Factor2:Nurses’confidenceindeliveringphysicalhealthcare(5items).Factor3:Perceivedbarrierstophysicalhealthcaredelivery(5items).Factor4:Attitudestosmokingandnegativebeliefs(6items).

     |  7ÖZASLAN et AL.

was identified as the most important (54%), followed by helpingpatientswithweightmanagement (39%),smokingcessation (36%),physicalexercise(38%)andcancerprevention(44%).

3.4 | Validity and reliability testing of the PHASe

3.4.1 | Construct validity and principal component analysis

Exploratory factor analysis (EFA) was used to perform constructanalysis of the PHASe (Osborne & Fitzpatrick, 2012). The KMOvalueofsamplingadequacyforthesample'sresponses is0.80, in‐dicating EFA's appropriateness (Cerny & Kaiser, 1977). Bartlett'ssphericity testprovidedap‐valueof<.001, so thenullhypothesiscouldberejected,andthefactorabilityofthecorrelationmatrixwassupported(Sharma,1996).

Exploratory factor analysis using PCA with varimax rotationwas conducted, and four components with eigenvalues exceed‐ing1were identified (Girden&Kabacoff,2010),whichexplained51.3%ofthevarianceobserved.Anexaminationofthecorrelationmatricesindicatedapotential4‐componentsolution,so3‐,4‐and5‐factormodelswereevaluatedfortheoreticalandstructuralade‐quacy.Severalitems(i.e.4,14,20and24)loadedweakly(>0.30)intheanalyses,sothese itemswereremovedfromsubsequentEFAiterations.

Thefinalmodelincluded4componentsbasedon24oftheorig‐inal28items.Thismodelexplained51.3%oftheoverallscalevari‐anceobserved.Thefactorstructureismostlysimilartothatoftheoriginalinstrumentdeveloped(Robson&Haddad,2012).However,thefourthfactor,ratherthanbeingrelatedsolelytosmoking,com‐bined several items (i.e. 7, 13 and27)with itemsonnegative anddeterministicviewsofhealthpromotion.ThefactoranalysismatrixispresentedbelowinTable2.

3.4.2 | Internal consistency

TheCronbach'salphameasureofinternalconsistencyforthetrans‐lated24‐itemscalewas0.83,whilethecomplete28‐itemversion'sscorewas0.82.TheCronbach'salphaofthesub‐scalesandthecom‐plete24‐itemscaleareshowninTable3.

3.4.3 | CFA

Confirmatoryfactoranalysisindicatedthata4‐factorsolutionwasthemodelthatbestfitthedata.Therootmeansquareerrorofap‐proximationwaswithintherangeofreasonablefitat0.08(Browne&Cudeck,1992).Thestandardizedrootmeansquareresidualwasalsoadequateat0.08(Hu&Bentler,1999),andthechi‐square/de‐greesof freedomvaluewas2.19,which showedan acceptable fit(Hooper,Coughlan,&Mullen,2008).Theanalysisfurtherrevealedaconsensusbetweenthescreeplot(seeFigure1)andmodelfitmeas‐uresinfavourofthe4‐factormodel.

3.4.4 | Test–retest reliability

Asub‐setof15respondentscompleted(Bujang&Baharum,2017)thePHASeagainafter2weekstoenablethescale'stest–retestreli‐abilitytobecheckedforthissampleusinganintraclasscorrelationcoefficient(ICC)with95%confidenceintervals.Significantcorrela‐tionswereevident foreachof thesub‐scales,withscores rangingfrom0.65forperceivedbarrierstophysicalhealthcaredeliveryto0.97forattitudestosmokingandnegativebeliefs.

3.5 | Nurses' attitudes measured by PHASe

Theextentof agreement foreach itemof thePHASe,withmeanscoresandSDs,isshowninTable4.Regardingmentalhealthnurses'attitudestowardsinvolvementinphysicalhealthcare(i.e.sub‐scale1),theyweregenerallypositiveabouttheirrole.Theseprofession‐als' confidence in delivering physical health care (i.e. sub‐scale 2)hadthehighestmeanvalueofallthesub‐scales.Theresponsestoitems assessing perceived barriers to physical healthcare delivery(i.e. sub‐scale 3) had the lowestmean value, which provides evi‐denceofpositive attitudes. Sub‐scale4 also showeda consistentmeanvalue indicatingpositiveattitudesaboutsmokingandnega‐tivebeliefs.

4  | DISCUSSION

Thisstudywasthefirst toexaminetheattitudesofmentalhealthnursesinTurkeytowardsprovidingphysicalhealthcaretoindividu‐alswithSMI,byusingavalidatedmeasurementtool.Withrespecttothedualaimsofthisstudy,thefirstaim,whichisthevalidityandreliability of the PHASe,was reachedwith several differences ontotalitemsincludingthenumberofitemsandthefactorstructure.PsychometrictestingofthePHASeproducedresultsindicatingthatthe Turkish version functions appropriately and that it can be re‐gardedasavalidandreliabletool,albeitwith24ratherthanthefull28items.WhilepsychometricassessmentsofthescaleshowedthatthetranslatedPHASehadvalidityandreliability,someparticularlysignificant findings were produced by factor analysis, specificallywithEFA.TheEFAresultsincludedsomeitems(i.e.1,2and7)thatloadsignificantlyondifferentfactorsatthesametime.Althoughthedifferencebetweenthefactorloadingswas<0.1,theseitemswerenotdiscardedfromthescaleasthefactorloadingswereoptimalattheitems'original locations(Fırat&Özden,2015). Item1(Helpingclientsmanagetheirweightshouldbepartofmentalhealthnurses'role)anditem2(Givingnutritionaladvicetoclientsshouldbepartofmentalhealthnurses'role)assessattitudestowardsinvolvementinphysicalhealthcare.However, these itemsalso tooksignificantloadsintermsofthesecondfactor,whichwasassociatedwiththenurses'self‐confidenceindeliveringphysicalhealthcare.Inaddition,inarecentstudy(Sirenetal.,2018),item2receivedappropriatefac‐torloadonthe“perceivedbarrierstophysicalhealthcaredelivery”

8  |     ÖZASLAN et AL.

sub‐scaleratherthanthe“attitudestoinvolvementinphysicalhealthcare”.Also,item1wasdiscardedfromthescale(Sirenetal.,2018).Inthiscase,itisseenthattheperceptionsofnurses'regardingtherolesrelated to nutrition issues can differ in different cultures. Resultsfromdifferentcountriesshowthatmentalhealthnursesdonotseecounsellingroles(i.e.givingnutritionaladvice)aspartoftheirrolesinacutepsychiatriccare(Sirenetal.,2018).

Whilethefourthfactoronlycoversattitudestowardssmokingintheoriginalscale,otheritemsthatassessnegativeattitudesrelatedto health promotion were also combined with attitudes towardssmoking in the present study. For this reason, this factor's namewaschanged,anditwasreorganizedinto“attitudestosmokingandnegativebeliefs”.Theresultsthusindicatethatculturaldifferencescanaffectitems'factorloadings.Inaddition,factorloadingscanbeimprovedbyincreasingthesamplesize(Ximénez,2016),soretestingthetranslatedscalewithlargersamplemaybenecessary(Karaman,Atar,&ÇobanoğluAktan,2017).Item7isanegativeattitudestate‐ment related to nurses' health promotion role, which states thatthesenurses'roledoesnotincludeconfirmingwithclientswhetherthey have had cancer screening checks.Notably, item 7 took theappropriate factor loading in terms of the first factor (i.e. nurses'attitudestoinvolvementinphysicalhealthcare).Nonetheless,thisitemwaskeptonthescalefocusedonthefourthfactor,inwhichanappropriatefactorloadingalsoappears,becauseofnurses'negativeattitudetowardsthisitem.

Whenconsideringhowtointerpretthesurveyfindings(thesec‐ondaimofthisstudy)onphysicalhealthwithSMIs,Turkishmentalhealthnurses showdifferences includingmonitoringglucose lev‐els, assessingbowelhabits, routinelycheckingweightandensur‐ingphysicalhealth. It is foundthat theydo thesepracticesmorecommonly at first contact than the mental health nurses in theUK(Haddad,Llewellyn‐Jones,Yarnold,&Simpson,2016;Robson,Haddad,etal.,2013).Ontheotherhand,thesefindingsaresimilarto the studies from threeAsian countries (i.e.Qatar,HongKongand Japan) (Bressingtonet al., 2018) and from Jordan (Ganiahetal.,2017).Someofthisdifferenceisprobablyrelatedtothepres‐entTurkishsamplebeingbasedentirelyonnurses inan inpatientcare setting,whereas other studies have recruited nurse partici‐pants fromboth inpatientandcommunity‐practicecontexts.Thecurrentresearch'srespondentsfocusedonthebasicphysiologicalindicatorsofphysicalhealthcare,whichsuggeststhatmostnursesinthesamplegraduatedfromgenericnursingprogrammes.Wheninterpreting the results of PHASe, researchers need to considertheenvironment inwhichnurseswork. InTurkey,theMinistryofHealthhasnotimplementedastandardprotocolforphysicalhealthcare,whichisalsotrueofmanagersinthehospitalinwhichthesur‐veywasconducted.Afteranysignificantchangeinpatients'healthstatus, collaborative treatment is provided. For example,when apatient's blood glucose rises, the relevant physician consultationisrequested,andbloodglucose levelsaremonitored. Inaddition,nursescanimplementmeasuresindependentlybasedontheirex‐isting knowledge.Themost standard intervention is thephysicalhealthdiagnosisprovidedwhentakingamedicalhistory,whichthe

hospital'sadministrationhasmadecompulsory,afterwhich inter‐ventionsarenotcontinuedunlessasignificantproblemappears.

Regardingmentalhealthnurses'attitudestowardsinvolvementin physical health care, the respondents are generally positiveabouttheirrole.However,theyalsoreportedlessagreementwiththeirroleineyeand/ordentalhealthchecksandsexualhealthpro‐motionformen.Thesurvey'sresultsforthenurses'currentprac‐ticesshowedthatoral/dentalhealthandsexualhealthcounsellingwerenoton the listof themost commonpractices,whilea fewnurses(n=42)routinelypracticeeyechecks.Thealarmingtruthisthatnursesapplyonlybasicskillsindailyroutinesandthattheseprofessionals do not include health promotion activities in dailycare.However,mentalhealthnursesareespeciallywellplacedtoaddress these important health needs because of their role andcontactwithmentalhealthserviceusers(DepartmentofHealth&PublicHealthEngland,2016).

In addition, the present study found that health promotionpracticesareignored.Thelackofpracticeguidelinesinthemen‐talhealthcaresettingsofTurkeymaybeacontributoryfactorforthe lackofawarenessofnurses,especially in certainareas suchas sexual health, eye and/or dental checks. The current systemprovidessupport through in‐service trainingprogrammes,whichcould improve the attitudes of nurses. Based on the findings ofthe present study, mental health nurses should be made moreaware of the need for holistic physical and mental health care.Inaddition,nursemanagerscanbetterunderstandtheattitudes,practicesandtrainingneedsofthesenurses,thusfacilitatingthefirststepstowardsreal,functionalactionsinthedevelopmentofstandardprotocols.

The findings of this study showing the attitudes of nursestowardsdiscussingsexualhealthwithpatientsare similar to theinternational literature (Hughes, Edmondson, Onyekwe, Quinn,&Nolan,2018;Quinn&Happell,2015). It isthoughtthatknow‐ing the source of this negative attitude to sexual health is animportant issue (Hughes et al., 2018).Overall, researchers haveconcludedthattheintangiblestructureofsexualityconceptscov‐ers issuesperceivedasprivate,andnurses' lackofknowledge inthis area is related to the inadequacy of and negative attitudestowardsrelatedpractices(Hughesetal.,2018;Quinn,Happell,&Welch,2013).Hughesetal. (2018) report thatnursesareawareofthisrole,butthattheyarereluctanttodiscussduetopossiblerisks,embarrassmentordistressexperiences.Quinnetal. (2013)stated thatmentalhealthnurses tendtoavoiddiscussingsexualissues,butwithabrief training intervention, theybecameeagerforthisrole.InTurkey,Sabancıoğulları,Elvan,Kelleci,andDoğan(2011)conductedastudyinauniversityhospital,whichincludedanevaluationofnurses' patient careplans in apsychiatric clinicaccording to the Functional Health Patterns model and NorthAmericanNursingDiagnosisAssociation(NANDA)diagnoses.Theresults revealed that the nurses collected the least data on sexandreproductive functions.Anotherstudycarriedout inTurkeybyTaşdemirandKızılkaya(2013)soughttodeterminethenursingdiagnosesfrequentlymadebynursesenrolledinamentalhealth

     |  9ÖZASLAN et AL.

andpsychiatricnursingprogramme.Thefindingsincludedthatnosexuality‐relateddiagnosesaremade.Itisseeninthefewstudiesconducted inTurkey that nurses have limitedproficiency in thisarea (Sabancıoğullarıetal.,2011;Taşdemir&Kızılkaya,2013). Inaddition,itisthoughtthattheissuesthatcauseconcernfornursesaboutdiscussingsexualhealthidentifiedindifferentculturesarevalidforTurkishnursesaswell.

Anexaminationofthecurrentsample'sresponsestothePHASeconfirmednurses'attitudesweremostlypositive towardsphysicalhealthcarepractices(e.g.givingadviceonhowtopreventheartdis‐ease [item6], andhelpingclientsmanage theirweight [item1]).Asignificantnumberofnursesreportedtheneedfortraininginrelatedfields,whichshowsnurses'sensitivitytotheproblem.

The ratings of the respondents indicate levels of confidence intheirdeliveryofphysicalcare thataregreater thanthosefoundbythestudiesintheUK,Asiancountries(Bressingtonetal.,2018;Reillyetal.,2012)andJordan(Ganiahetal.,2017).Adirectcomparisonofthecurrent resultswithmentalhealthnurses inJordanwas limitedbydifferencesinthewayresultswerereported,butthefindingsin‐dicatedlessofadivergenceinviews.TheTurkishnurses'highlevelofconfidencecouldalsobe related to in‐service trainingprogrammesregularly offered as part of the hospital's protocol, which meansnurses'practicesareroutinelysupportedbyphysicalcareeducationandtraining.Theseprofessionals'tendencytorelyontheirbasicnurs‐ingskillsmaybeduetoTurkey'sinadequateacceptanceoralackofawarenessofspecificmentalhealthnursingrolesininpatientsettings.

AttitudedifferencesbetweenUKandTurkishnursesweremostpronounced in relation to perceived barriers to the provision ofphysicalhealthcare.ResponsestoallfiveattitudestatementsweremarkedlylesspositivethanfortheUKsample(Reillyetal.,2012).Thegreatestdifferenceshowedupinreferencetotwostatements:“Myworkloadpreventsmefromdoinganyphysicalhealthpromo‐tionwithclients”(63%agreementamongnursesinTurkeyvs.19%intheUK)and“Clientswithseriousmentalhealthproblemsarenotinterestedinimprovingtheirphysicalhealth”(60%vs.16%).Severalattitude itemswere adapted for use in a study ofmental healthnurses in theUnitedStates,with results similarly indicatingmorepositive views than the present Turkish sample showed (Knight,Bolton,&Kopeski,2017).Thesenurses'negativeattitudescouldre‐ducethequality‐of‐caredelivery,and,asaresult,patientswithSMImaymissouton receiving theappropriatenursingcare—whether

mental or physical. Nonetheless, mental health nurses' attitudestowards their involvement in physical health carewere generallypositive,eventhoughstaffshortagescouldmakeperformingeventhemostbasicphysical careand/orpromotionactivitiesdifficult.The additional problem of perceived barriers could be related tostigmatizationofmentalillnessand/ormentallyillpeople.

Pronounceddifferences inattitudeswerealsodetectedcon‐cerning smoking and smoking cessation. Nurses in the currentsamplewerefarmorelikelythanUKandAsiannursestofeelthatcigarettes could be used for therapeutic purposes and that pa‐tientsshouldnotbeencouragedtoquit.Nursesworkinginmentalhealth units in Jordan reported similar views to those in Turkeyaboutsmoking'sacceptabilityandtherapeuticuse,buttheformersampleweremuchmorelikelytoendorsesmokingbeingbannedfor both patients and staff on healthcare facilities' premises. Inthepresentsample,approximatelyone‐quarterofthenurseshadanegativeattitudetowardssmoking,andone‐thirdassertedthattheyneedadditionaltrainingaboutsmokingcessation.Comparedtonurses inAsiancountries (Bressingtonetal.,2018), forwhomsmoking habits ranged from 1% to 7% of the sample, and theUKnurses'21%(Robson&Haddad,2012),nurses in thecurrentstudyweremuchmorelikelytobesmokers(42%).Thisisrelatedin part tohigher ratesof smoking inTurkey than in theseothernations, although, apparently, the prevalenceof smoking amongnursesinTurkeyexceedsthenationalrateof27%(WorldHealthOrganization,2015).PreviousstudiesshowthattheprevalenceofsmokingamongnursesinTurkeyexceedstherateof45%(Sezer,Guler,&Sezer,2007;Tezcan&Yardım,2003).

Thepresentsampleofnursesfurtherhadnegativeattitudesaboutconfirming with clients whether they have had cancer screeningchecks.Thesediagnosticproceduresareusuallyperformedbyphysi‐cians,butnursescanplayanimportantroleinearlydiagnosis.Nurses'negative attitudes were reinforced by perceived barriers related toworkloads preventing them from implementing health promotionpracticesandtheirlowlevelofknowledgeaboutthetopic,especiallyas44%ofthosesurveyednotedtheneedfortrainingincancerpreven‐tion.Theseattitudesappeartobesimilartothosedetectedbyprevi‐ousstudies(Ganiahetal.,2017;Howard&Gamble,2011).

Themeasurementof theattitudesofmentalhealthnurses to‐wards providing physical health care with a reliable tool is thefirststageof thepractices thatcanbeestablishedto improvethe

TA B L E 3  Scaleinternalconsistencyvalues Sub‐scales Cronbach's Alpha Mean ± SD

Nurses'attitudestoinvolvementinphysicalhealthcare

0.88 3.47±0.79

Nurses'confidenceindeliveringphysicalhealthcare

0.71 4.11±0.58

Perceivedbarrierstophysicalhealthcaredelivery

0.64 2.47±0.65

Attitudestosmokingandnegativebeliefs 0.74 3.31±0.76

Totalscale 0.83 3.42±0.36

Abbreviations:M,mean;SD,standarddeviation.

10  |     ÖZASLAN et AL.

attitudesofnurses.Furthermore, identifyingtheirperceivedbarri‐erswillprovideinsightaboutthecareoffered.Therefore,itiscon‐sideredimportanttointroducethePHASeintopractice.Thus,thisstudy,whichdeterminesthepsychometricpropertiesof thescale,suggeststhatitisimportantandnecessarytousethePHASewithintheTurkishmentalhealthcontext.

5  | CONCLUSION

5.1 | Study strengths and limitations

ThisstudywasthefirsttoinvestigateTurkishmentalhealthnurses'involvementandattitudestowardsphysicalhealthcarebasedonavalidatedmeasurementinstrument.Theresearch'sdesignenabledacomparisonofthefindingswithstudiesconductedinothersettings,aswellasanexaminationofchangeswithinthesamecontextovertimeandinrelationtofactorssuchaspoliciesoreducationinnova‐tions.Thefactoranalysisandreliabilitytests'results indicatedthePHASeissuitableformeasuringkeyfactorsrelevanttothisimpor‐tantareaofpractice.Theresponserateof83%obtainedimpliesalowpotentialforbiasduetonon‐response.

However, the convenience sample was based on respondentsrecruitedfromasinglehospitalinIstanbul,whichisakeylimitation.Inaddition,thesamplecomprisednurseswhoworkininpatientclin‐ics,whichconstitutesanother important limitation.Theseaspectsof the research design limit the sample's representativeness and,therefore, the findings' generalizability to thewider populationofTurkishnursesworkinginmentalhealthcare.However,theselectedhospitalisthelargestmentalhealthfacilityinTurkey.

This study's findingswere alsobasedonnurses' personal per‐ceptions, thus potentially reflecting respondents' bias and mak‐ing theprovisionof informationdifficult in termsof the level and

accuracy of the nurses' current practices.Data on the content oftrainingswerelimitedtohospitalprotocols.Afurthermethodologi‐callimitationwasthetotalvarianceof51.3%explained,whichshowstheinstrumentneedsfurtherimprovement,althoughincreasingthesamplesizecouldimprovetheresults.Becausethisresearchusedacross‐sectionaldesign,theinferencesthatcanbemadeaboutcau‐salityarelimited.Nonetheless,theassociationsidentifiedbetweenattitudes,priorspecialisttrainingandinvolvementinphysicalhealthcare concurwith other studies' findings on this topic, providing avaluablebasisforfurtherinvestigations.

5.2 | Findings

Thepresent findings indicated that thePHASe is a valid and reli‐ablemeasurementinstrumentindifferentculturesandthatTurkishnursesworking inmental health generally have positive attitudestowards physical health care. However, these professionals havenegativeviewsaboutsomehealthpromotionpractices(e.g.cancerscreening and eye checks). The respondents also noted that theyneedmore training inmanaging cardiovascularhealth,weight andsmokingcessation.Thefindingsincludecleardifferencesinsmokingattitudesbetweencountries.Turkishnursesshowedatendencytousesmokingfortherapeuticpurposes.Thus,mentalhealthnurses'knowledge, views and attitudes towardsprovidingphysical healthcareshouldbeenhancedbyadditionaltraining.Structuredtrainingfocusingonamoreholisticapproachneedstobeprovidedtohelpnursescareforallaspectsofpatients'health.

5.3 | Relevance for mental health nursing

This paper adds to the existing knowledge about mental healthnurses'attitudestowardsprovidingphysicalhealthcaretopatients

F I G U R E 1  ScreeplotfortheEFAforthePHASeadministeredinTurkey

     |  11ÖZASLAN et AL.

withSMI.Thestudy'sresultscontributetotheimportantdiscussionofdataonfirst‐timeimplementationofthePHASeinadifferentlan‐guage.Nurses' attitudes are a crucial componentencouraging theprovisionofphysicalhealthcarethatcanenhancepatientfunction‐ality,qualityof lifeand lifeexpectancy.For this reason,additionaltraining formental healthnurses canbedeveloped to strengthennurses'positiveattitudes. Inaddition,thepresentresultshighlightvariousbarriers toprovidingphysicalhealthcare, including inade‐quatetraining,anoverlyhighlevelofconfidenceandconflictingrole

priorities.Trainingcanalsobeaneffectivewaytoencouragenursestoadoptmind–bodyintegrityaspartoftheirscopeofpractice.

6  | RELE VANCE STATEMENT

Inthisstudy,theattitudesofmentalhealthnursestowardsinvolve‐mentinphysicalhealthcareandsmoking,theirconfidenceindeliv‐eringphysicalhealthcare,perceivedbarriersandnegativebeliefs

TA B L E 4  Nurses'attitudesandconfidence:ratingsonPHASe,orderedbyextentofagreement

PHASe sub‐scale items

Number in agreement (strongly agree/ agree)

N % Mean ± SD

Nurses'attitudestoinvolvementinphysicalhealthcare

2Givingnutritionaladvicetoclientsshouldbepartofamentalhealthnursesrole 145 83.3 3.95 0.89

1Helpingclientsmanagetheirweightshouldbepartofthementalhealthnurses'role 129 74.1 3.75 1.09

17Mentalhealthnursesshouldeducatefemaleclientsabouttheimportanceofbreastself‐examination

123 70.7 3.73 1.00

11Mentalhealthnursesshouldprovideclientswithcontraceptiveadvice 121 69.6 3.69 1.12

6Givingadviceonhowtopreventheartdiseaseshouldbepartofthementalhealthnurses'role

104 59.7 3.55 1.07

10Ensuringclientsareregisteredwithadentistshouldbepartofthementalhealthnurse'srole

75 43.1 3.13 1.17

25Mentalhealthnursesshouldeducatemaleclientsabouttheimportanceoftesticularself‐examination

71 40.8 3.11 1.12

22Ensuringclientshavetheireyesregularlycheckedbyanopticianshouldbepartofthementalhealthnurse'srole

51 29.3 2.83 1.10

Nurses'confidenceindeliveringphysicalhealthcare

8IamconfidentthatIcanmeasureaclient'sblood‐pressureaccurately 166 95.4 4.69 0.73

19Iamconfidentinassessingsignsandsymptomsofhypoglycaemia 154 88.5 4.30 0.76

3Iamconfidentinassessingsignsandsymptomsofhyperglycaemia 149 85.7 4.11 0.84

26IamconfidentthatIcouldresuscitateaclientwhohadacardiacarrest 140 80.4 4.02 0.98

21IamconfidentthatIknowwhichpsychotropicdrugsincreasetheriskthataclientmayexperiencecardiacproblems

85 48.9 3.41 0.96

Perceivedbarrierstophysicalhealthcaredelivery

9Itisdifficulttogetclientstofollowadviceonhowtomanagetheirweight 135 77.5 3.80 0.87

18Itisdifficulttogetclientstofollowhealthy‐eatingadvice 127 73.0 3.69 0.84

23Myworkloadpreventsmedoinganyphysicalhealthpromotionwithclients 109 62.6 3.56 1.12

5Clientswithseriousmentalhealthproblemsarenotinterestedinimprovingtheirphysicalhealth

103 59.2 3.41 1.25

15Clientsarenotmotivatedtoexercise 87 50.0 3.17 1.05

Attitudestosmokingandnegativebeliefs

27Clients'physicalhealthworriesaremostlyduetotheirmentalillness 68 39.0 3.06 1.00

7Itshouldnotbethementalhealthnurseroletocheckwithaclientiftheyhavehadcancerscreeningchecks(i.e.cervicalsmear/mammogram)

60 34.5 2.78 1.15

13Informingclientsaboutthepossibleeffectsofmedicationmayhaveontheirphysicalhealthwillincreasenon‐adherence

50 28.7 2.67 1.20

16Clientsshouldbegivencigarettestohelpachievetherapeuticgoals 45 25.9 2.65 1.10

12Clientsshouldnotbeencouragedtogiveupsmoking,astheyhaveenoughtocopewith 44 25.3 2.56 1.20

28Staffandclientssmokingtogetherhelpstobuildatherapeuticrelationship 39 22.4 2.39 1.30

Abbreviations:%,percentages;M,mean;n,frequency;PHASe,PhysicalHealthAttitudeScale;SD,standarddeviation.

12  |     ÖZASLAN et AL.

were determined in terms of the physical health care of patientswith seriousmental illnesses.The studyalsoprovidesanewvali‐datedscalethatcontributestothenationalliterature.Althoughem‐phasishasclearlybeenplacedonmentalhealthnurses' importantroleinthephysicalhealthofindividualswithseriousmentalillness,theliteraturerevealsthatnurses'variableattitudestowardsphysi‐calhealthcarehindertherealizationofthisrole.Attitudestowardshealth promotion practices need to be improved, in conjunctionwiththedeterminationofwhichfunctionalobjectivesshouldbeim‐plemented.TheattitudesofTurkishmentalhealthnursesincludedlessinvolvementinhealthpromotionpractices,aswellastheirbe‐liefstowardsusingsmokingfortherapeuticpurposesreflectedtheneedsoftraining.Thisstudyrevealstheattitudesofnursesworkingin acutemental healthwards towards the physical health care ofindividualswith seriousmental illnesseswithin the framework ofholisticcare.

ACKNOWLEDG MENTS

Theauthorsdeclarethatthereisnoanyfinancialsupportorrelation‐shipsthatmayposeconflictofinterest.

CONFLIC T OF INTERE S T

Noconflictofinteresthasbeendeclaredbytheauthors.

AUTHOR CONTRIBUTION

Allauthorslistedmeettheauthorshipcriteriaaccordingtothelat‐est guidelines of the International Committee ofMedical JournalEditors,andallauthorsareinagreementwiththemanuscript.

E THIC AL APPROVAL

ThestudywasapprovedbytheEthicsCommitteeoftheBakırköyMentalHealthandNeurologicalDiseasesHospital(01.09.2015,No.487).

ORCID

Zeynep Özaslan https://orcid.org/0000‐0001‐9400‐7825

Hülya Bilgin https://orcid.org/0000‐0001‐7332‐5568

Suna Uysal Yalçın https://orcid.org/0000‐0002‐1048‐1448

Mark Haddad https://orcid.org/0000‐0002‐4822‐5482

R E FE R E N C E S

Alataş,G., Kahiloğulları, A. K., & Yanık,M. (2011).Ulusal Ruh Sağlığı Eylem Planı (2011–2023) (National Mental Health Action Plan 2011–2023). In Y. Erkoç, S. Çom, M. A. Torunoğlu, G. Alataş, & A. K.Kahiloğulları (Eds.), Ankara, Turkey: Publications of Ministry ofHealth.

Bartlem,K.,Bowman,J.,Ross,K.,Freund,M.,Wye,P.,McElwaine,K.,…Wiggers,J.(2016).Mentalhealthclinicianattitudestotheprovision

of preventive care for chronic disease risk behaviours and asso‐ciation with care provision. BMC Psychiatry, 16(1), 57. https://doi.org/10.1186/s12888‐016‐0763‐3

Bressington, D., Badnapurkar, A., Inoue, S., Ma, H. Y., Chien, W. T.,Nelson,D.,&Gray,R. (2018).Physicalhealthcare forpeoplewithseverementalillness:Theattitudes,practices,andtrainingneedsofnursesinthreeAsiancountries.International Journal of Environmental Research and Public Health,15(2),343.https://doi.org/10.3390/ijerph1502 0343

Brislin, R. W. (1970). Back‐translation for cross‐cultural research.Journal of Cross‐Cultural Psychology, 1(3), 185–216. https://doi.org/10.1177/135910457000100301

Browne,M.W.,&Cudeck,R.(1992).Alternativewaysofassessingmodelfit. Sociological Methods and Research, 21, 230–258. https://doi.org/10.1177/0049124192021002005

Bujang,M.A.,&Baharum,N.(2017).Asimplifiedguidetodeterminationofsamplesizerequirementsforestimatingthevalueofintraclasscor‐relationcoefficient:Areview.Archives of Orofacial Science,12(1),1‐11.

ÇelikInce,S.,PartlakGünüşen,N.,&Serçe,Ö. (2018).TheopinionsofTurkishmental health nurses on physical health care for individu‐alswithmentalillness:Aqualitativestudy.Journal of Psychiatric and Mental Health Nursing, 25(4), 245–257. https://doi.org/10.1111/jpm.12456

Cerny,C.A.,&Kaiser,H. F. (1977).A studyof ameasureof samplingadequacy for factor‐analytic correlation matrices. Multivariate Behavioral Research, 12(1), 43–47. https://doi.org/10.1207/s15327906mbr1201_3

Chesney,E.,Goodwin,G.M.,&Fazel,S.(2014).Risksofall‐causeandsui‐cidemortalityinmentaldisorders:Ameta‐review.World Psychiatry,13(2),153–160.https://doi.org/10.1002/wps.20128

Crump, C., Winkleby, M. A., Sundquist, K., & Sundquist, J. (2013).Comorbidities and mortality in persons with schizophrenia: ASwedishnationalcohortstudy.American Journal of Psychiatry,170(3),324–333.https://doi.org/10.1176/appi.ajp.2012.12050599

DeHert,M.,Detraux,J.,VanWinkel,R.,Yu,W.,&Correll,C.U.(2012).Metabolic and cardiovascular adverse effects associated with an‐tipsychotic drugs. Nature Reviews Endocrinology, 8(2), 114–126. https://doi.org/10.1038/nrendo.2011.156

DepartmentofHealthandPublicHealthEngland(2016). Improving the physical health of people with mental health problems: Actions for men‐tal health nurses.London,UK:DepartmentofHealth.

Dunbar, L.,Brandt,T.,Wheeler,A.,&Harrison, J. (2010).Barriers andsolutions to implementingmetabolic risk assessment in a second‐ary mental health service.Australasian Psychiatry, 18(4), 322–325. https://doi.org/10.3109/10398561003692571

Fırat,E.A.,&Özden,M. (2015).Developingascalefortheuseof ICTthroughscientificprocessofpreserviceteachers.Gazi University the Journal of Gazi Education Faculty,35(1),1‐25.

Fukada,M.(2018).Nursingcompetency:Definition,structureanddevel‐opment.Yonago Acta Medica, 61(1), 1–7. https://doi.org/10.33160/yam.2018.03.001

Ganiah,A.N.,Al‐Hussami,M.,&Alhadidi,M.M.(2017).MentalhealthnursesattitudesandpracticetowardphysicalhealthcareinJordan.Community Mental Health Journal, 53(6), 725–735. https://doi.org/10.1007/s10597‐017‐0143‐6

Girden, E. R., & Kabacoff, R. (Eds.). (2010). Evaluating research articles from start to finish.ThousandOaks,CA:Sage.

Haddad, M., Llewellyn‐Jones, S., Yarnold, S., & Simpson, A. (2016).Improvingthephysicalhealthofpeoplewithseverementalillnessinalowsecureforensicunit:Anuncontrolledevaluationstudyofstaff trainingandphysicalhealthcareplans. International Journal of Mental Health Nursing,25(6),554–565.https://doi.org/10.1111/inm.12246

Happell, B., Platania‐Phung, C., & Scott, D. (2014). What determineswhether nurses provide physical health care to consumers with

     |  13ÖZASLAN et AL.

seriousmental illness?Archives of Psychiatric Nursing,28(2),87–93.https://doi.org/10.1016/j.apnu.2013.11.001

Happell,B.,Scott,D.,Nankivell,J.,&Platania‐Phung,C.(2013).Screeningphysicalhealth?Yes!But…:Nurses'viewsonphysicalhealthscreen‐inginmentalhealthcare.Journal of Clinical Nursing,22(15–16),2286–2297.https://doi.org/10.1111/j.1365‐2702.2012.04325.x

Happell, B., Stanton, R., Hoey, W., & Scott, D. (2014). Development,validation and initial outcomes of a questionnaire to investigatetheviewsofnursesworking inamentalhealthsettingregardingacardiometabolichealthnursing role.Archives of Psychiatric Nursing,28(2),123–127.https://doi.org/10.1016/j.apnu.2013.12.003

Hardy,S.(2012).Trainingpracticenursestoimprovethephysicalhealthof patientswith severemental illness: Effects on beliefs and atti‐tudes.International Journal of Mental Health Nursing,21(3),259–265.https://doi.org/10.1111/j.1447‐0349.2011.00800.x

Hooper,D.,Coughlan,J.,&Mullen,M.(2008).Structuralequationmod‐elling: Guidelines for determining model fit. Electronic Journal of Business Research Methods,6(1),53–60.

Howard, L., & Gamble, C. (2011). Supporting mental health nursesto address the physical health needs of people with seri‐ous mental illness in acute inpatient care settings. Journal of Psychiatric and Mental Health Nursing, 18(2), 105–112. https://doi.org/10.1111/j.1365‐2850.2010.01642.x

Hu, L. T., &Bentler, P.M. (1999). Cutoff criteria for fit indexes in co‐variancestructureanalysis:Conventionalcriteriaversusnewalter‐natives.Structural Equation Modeling: A Multidisciplinary Journal,6(1),1–55.https://doi.org/10.1080/10705519909540118

Hughes,E.,Edmondson,A.J.,Onyekwe,I.,Quinn,C.,&Nolan,F.(2018).Identifying and addressing sexual health in seriousmental illness:ViewsofmentalhealthstaffworkingintwoNationalHealthServiceOrganizations in England. International Journal of Mental Health Nursing,27(3),966–974.https://doi.org/10.1111/inm.12402

Hyland,B.,Judd,F.,Davidson,S.,Jolley,D.,&Hocking,B.(2003).Casemanagers'attitudestothephysicalhealthoftheirpatients.Australian & New Zealand Journal of Psychiatry, 37(6), 710–714. https://doi.org/10.1080/j.1440‐1614.2003.01264.x

Jayatilleke,N.,Hayes,R.D.,Dutta,R.,Shetty,H.,Hotopf,M.,Chang,C.K.,&Stewart,R.(2017).Contributionsofspecificcausesofdeathtolostlifeexpectancyinseverementalillness.European Psychiatry,43,109–115.https://doi.org/10.1016/j.eurpsy.2017.02.487

Karaman,H.,Atar,B.,&ÇobanoğluAktan,D. (2017). The comparisonof factor extraction methods used in exploratory factor analysis.GUJGEF,37(3),1173–1193.

Knight,M.,Bolton,P.,&Kopeski, L. (2017).Providingphysical care topersonswithseriousmental illness:Attitudes,confidence,barriersand psychological empowerment. Archives of Psychiatric Nursing,31(5),447–453.https://doi.org/10.1016/j.apnu.2017.07.001

Kontopantelis,E.,Olier,I.,Planner,C.,Reeves,D.,Ashcroft,D.M.,Gask,L.,…Reilly, S. (2015).Primary care consultation rates amongpeo‐plewithandwithoutseverementalillness:AUKcohortstudyusingtheClinicalPracticeResearchDatalink.British Medical Journal Open,5(12),e008650.https://doi.org/10.1136/bmjopen‐2015‐008650

McBain,H.,Mulligan,K.,Lamontagne‐Godwin,F.,Jones,J.,Haddad,M.,Flood,C.,… Simpson,A. (2016). Implementation of recommendedtype2diabetescareforpeoplewithseverementalillness–aqualita‐tiveexplorationwithhealthcareprofessionals.BMC Psychiatry,16(1),222.https://doi.org/10.1186/s12888‐016‐0942‐2

Mitchell,A.J.,Delaffon,V.,Vancampfort,D.,Correll,C.U.,&DeHert,M.(2012).Guidelineconcordantmonitoringofmetabolicriskinpeo‐ple treated with antipsychotic medication: Systematic review andmeta‐analysis of screening practices. Psychological Medicine,42(1),125–147.https://doi.org/10.1017/S003329171100105X

Mitchell,A.J.,Malone,D.,&Doebbeling,C.C.(2009).Qualityofmed‐ical care forpeoplewith andwithout comorbidmental illness andsubstancemisuse:Systematicreviewofcomparativestudies.British

Journal of Psychiatry,194(6), 491–499. https://doi.org/10.1192/bjp.bp.107.045732

Mitchell,A.J.,Vancampfort,D.,DeHert,M.,&Stubbs,B. (2015).Dopeople with mental illness receive adequate smoking cessationadvice? A systematic review and meta‐analysis. General Hospital Psychiatry, 37(1), 14–23. https://doi.org/10.1016/j.genhosppsych. 2014.11.006

Morrison,P.,Meehan,T.,&Stomski,N.J.(2015).Australiancasemanagers'perceptionsofmental health consumersuseof antipsychoticmed‐ications and associated side‐effects. International Journal of Mental Health Nursing,24(2),104–111.https://doi.org/10.1111/inm.12118

Nash,M. (2005).Physicalcareskills:Atrainingneedsanalysisof inpa‐tient and communitymental health nurses.Mental Health Practice,9(4),20–24.https://doi.org/10.7748/mhp2005.12.9.4.20.c1896

Osborn,D. P.,Nazareth, I., &King,M. B. (2007). Physical activity, di‐etary habits and Coronary Heart Disease risk factor knowledgeamongst people with severe mental illness. Social Psychiatry and Psychiatric Epidemiology, 42(10), 787–793. https://doi.org/10.1007/s00127‐007‐0247‐3

Osborne,J.W.,&Fitzpatrick,D.C.(2012).Replicationanalysisinexplor‐atoryfactoranalysis:Whatitisandwhyitmakesyouranalysisbetter.Practical Assessment, Research & Evaluation,17,15.

Quinn,C.,&Happell,B. (2015).Consumersexualrelationships inafo‐rensicmentalhealthhospital:Perceptionsofnursesandconsumers.International Journal of Mental Health Nursing,24(2),121–129.https://doi.org/10.1111/inm.12112

Quinn, C., Happell, B., &Welch, A. (2013). Talking about sex as partof our role: Making and sustaining practice change. International Journal of Mental Health Nursing, 22(3), 231–240. https://doi.org/10.1111/j.1447‐0349.2012.00865.x

Reilly, S., Planner, C., Hann,M., Reeves, D., Nazareth, I., & Lester, H.(2012).TheroleofprimarycareinserviceprovisionforpeoplewithseverementalillnessintheUnitedKingdom.PLoS ONE,7(5),e36468.https://doi.org/10.1371/journal.pone.0036468

Robson,D.,Cole,F.,Jalasi,S.,Boojharut,B.,Smith,S.,Thompson,S.,…Haddad,M.(2013).Smokingcessationandseriousmentalillness:Aserviceevaluationofadrop‐instopsmokingcliniconanacutein‐pa‐tientunit.Journal of Clinical Nursing,22(3–4),405–413.https://doi.org/10.1111/j.1365‐2702.2012.04222.x

Robson,D., &Haddad,M. (2012).Mental health nurses' attitudes to‐wardsthephysicalhealthcareofpeoplewithsevereandenduringmentalillness:Thedevelopmentofameasurementtool.International Journal of Nursing Studies, 49(1), 72–83. https://doi.org/10.1016/j.ijnurstu.2011.07.011

Robson,D.,Haddad,M.,Gray,R.,&Gournay,K. (2013).Mentalhealthnursingandphysicalhealthcare:Across‐sectionalstudyofnurses'attitudes, practice, and perceived training needs for the physi‐cal health care of people with severe mental illness. International Journal of Mental Health Nursing, 22(5), 409–417. https://doi.org/10.1111/j.1447‐0349.2012.00883.x

Royal College of Physicians, Royal College of Psychiatrists (2013).Smoking and mental health: Royal College of Psychiatrists Council Report CR178.London,UK:RCP.

Royal College of Psychiatrists (2014). Report of the second round of the National Audit of Schizophrenia (NAS). London,UK:Health careQualityImprovementPartnership.

Sabancıoğulları, S., Elvan, E.,Kelleci,M.,&Doğan, S. (2011).Bir psiki‐yatrikliniğindehemşirelertarafındanyapılanhastabakımplanlarınınFonksiyonel Sağlık Örüntüleri Modeli ve NANDA tanılarına göredeğerlendirilmesi.Journal of Psychiatric Nursing,2(3),117–122.

Sezer,H.,Guler,N.,&Sezer,R.E.(2007).SmokingamongnursesinTurkey:Comparisonwithothercountries.Journal of Health, Population, and Nutrition,25(1),107.

Sharma, S. (1996).Applied multivariate techniques.NewYork,NY: JohnWileyandSonsInc.

14  |     ÖZASLAN et AL.

Shefer, G., Henderson, C., Howard, L. M., Murray, J., & Thornicroft, G.(2014).Diagnosticovershadowingandotherchallengesinvolvedinthediagnosticprocessofpatientswithmentalillnesswhopresentinemer‐gencydepartmentswithphysicalsymptoms–aqualitativestudy.PLoS ONE,9(11),e111682.https://doi.org/10.1371/journal.pone.0111682

Siren, A., Cleverley, K., Strudwick, G., & Brennenstuhl, S. (2018).Modification and initial psychometric evaluation of the PhysicalHealthAttitudeScaleforuseintheCanadianmentalhealthandad‐dictions context. Issues in Mental Health Nursing,39(11), 946–953.https://doi.org/10.1080/01612840.2018.1475523

Tabachnick,B.G.,&Fidell,L.S. (2013).Using multivariate statistics (6thed.).Harlow,UK:PearsonEducationLimited.

Taşdemir,G.,&Kızılkaya,M. (2013).EvaluationofNANDAnursingdi‐agnosesofhealthcarecollegefinalyearstudentsduringtheclinicalapplicationofthementalhealthanddiseasenursingcourse.Journal of Human Sciences,10(1),246–257.

Tezcan,S.,&Yardim,N.(2003).Prevalenceofsmokingbetweenthedoc‐tors,nursesandmedicalfacultystudentsatsomehealthfacilitiesinTurkey.Journal of Tuberculosis and Thorax,51(4),390–397.

Tylee, A., &Haddad,M. (2007).Managing complex problems: Treatmentfor commonmental disorders in theUK.Epidemiology and Psychiatric Sciences,16(4),302–308.https://doi.org/10.1017/S1121189X00002487

Von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C.,Vandenbroucke,J.P.,&Initiative,S. (2007).TheStrengtheningtheReportingofObservationalStudiesinEpidemiology(STROBE)state‐ment: Guidelines for reporting observational studies. PLoS Med,4(10),e296.https://doi.org/10.1371/journal.pmed.0040296

World Health Organization (2015). WHO global report on trends in prevalence of tobacco smoking 2015. Geneva, Switzerland: WorldHealth Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/156262/1/9789241564922_eng.pdf

Wye,P.,Bowman,J.,Wiggers,J.,Baker,A.,Carr,V.,Terry,M.,…Clancy,R. (2010). Providing nicotine dependence treatment to psychiat‐ric inpatients: The views of Australian nurse managers. Journal of Psychiatric and Mental Health Nursing, 17(4), 319–327. https://doi.org/10.1111/j.1365‐2850.2009.01524.x

Ximénez, C. (2016). Recovery of weak factor loadings when addingthe mean structure in confirmatory factor analysis: A simulationstudy. Frontiers in Psychology, 6, 1943. https://doi.org/10.3389/fpsyg.2015.01943

How to cite this article:ÖzaslanZ,BilginH,UysalYalçınS,HaddadM.Initialpsychometricevaluationofthephysicalhealthattitudescaleandasurveyofmentalhealthnurses.J Psychiatr Ment Health Nurs. 2019;00:1–15. https://doi.org/10.1111/jpm.12553

APPENDIX S TROBE St atement— Check l i s t of i tems that should be inc luded in repor t s of c r o s s‐s e c t i o n a l s tu d i e s

Item No. Recommendation Page no.

Titleandabstract 1 (a)Indicatethestudy’sdesignwithacommonlyusedterminthetitleortheabstract

1

(b)Provideintheabstractaninformativeandbalancedsummaryofwhatwasdoneandwhatwasfound

1–3

Introduction

Background/rationale 2 Explainthescientificbackgroundandrationalefortheinvestigationbeingreported

3–6

Objectives 3 State‐specificobjectives,includinganyprespecifiedhypotheses 7

Methods

Studydesign 4 Presentkeyelementsofstudydesignearlyinthepaper 7

Setting 5 Describethesetting,locationsandrelevantdates,includingperiodsofrecruit‐ment,exposure,follow‐upanddatacollection

7

Participants 6 (a)Givetheeligibilitycriteria,andthesourcesandmethodsofselectionofparticipants

7

Variables 7 Clearlydefinealloutcomes,exposures,predictors,potentialconfoundersandeffectmodifiers.Givediagnosticcriteria,ifapplicable

–

Datasources/measurement 8*  Foreachvariableofinterest,givesourcesofdataanddetailsofmethodsofassessment(measurement).Describecomparabilityofassessmentmethodsifthereismorethanonegroup

8

Bias 9 Describeanyeffortstoaddresspotentialsourcesofbias 9

Studysize 10 Explainhowthestudysizewasarrivedat 10

Quantitativevariables 11 Explainhowquantitativevariableswerehandledintheanalyses.Ifapplicable,describewhichgroupingswerechosenandwhy

–

(Continues)

     |  15ÖZASLAN et AL.

Item No. Recommendation Page no.

Statisticalmethods 12 (a)Describeallstatisticalmethods,includingthoseusedtocontrolforconfounding

11

(b)Describeanymethodsusedtoexaminesubgroupsandinteractions –

(c)Explainhowmissingdatawereaddressed –

(d)Ifapplicable,describeanalyticalmethodstakingaccountofsamplingstrategy

–

(e)Describeanysensitivityanalyses –

Results

Participants 13*  (a)Reportnumbersofindividualsateachstageofstudy—e.g.numberspoten‐tiallyeligible,examinedforeligibility,confirmedeligible,includedinthestudy,completingfollow‐upandanalysed

11

(b)Givereasonsfornon‐participationateachstage –

(c)Consideruseofaflowdiagram –

Descriptivedata 14*  (a)Givecharacteristicsofstudyparticipants(e.g.demographic,clinical,social)andinformationonexposuresandpotentialconfounders

11

(b)Indicatenumberofparticipantswithmissingdataforeachvariableofinterest

–

Outcomedata 15*  Reportnumbersofoutcomeeventsorsummarymeasures –

Mainresults 16 (a)Giveunadjustedestimatesand,ifapplicable,confounder‐adjustedestimatesandtheirprecision(e.g.95%confidenceinterval).Makeclearwhichconfound‐erswereadjustedforandwhytheywereincluded

11–14

(b)Reportcategoryboundarieswhencontinuousvariableswerecategorized –

(c)Ifrelevant,considertranslatingestimatesofrelativeriskintoabsoluteriskforameaningfultimeperiod

–

Otheranalyses 17 Reportotheranalysesdone—e.g.analysesofsubgroupsandinteractions,andsensitivityanalyses

–

Discussion

Keyresults 18 Summarizekeyresultswithreferencetostudyobjectives 14–20

Limitations 19 Discusslimitationsofthestudy,takingintoaccountsourcesofpotentialbiasorimprecision.Discussbothdirectionandmagnitudeofanypotentialbias

21

Interpretation 20 Giveacautiousoverallinterpretationofresultsconsideringobjectives,limita‐tions,multiplicityofanalyses,resultsfromsimilarstudiesandotherrelevantevidence

21–22

Generalizability 21 Discussthegeneralizability(externalvalidity)ofthestudyresults 22

Otherinformation

Funding 22 Givethesourceoffundingandtheroleofthefundersforthepresentstudyand,ifapplicable,fortheoriginalstudyonwhichthepresentarticleisbased

–

Note:AnExplanationandElaborationarticlediscusseseachchecklistitemandgivesmethodologicalbackgroundandpublishedexamplesoftranspar‐entreporting.TheSTROBEchecklistisbestusedinconjunctionwiththispaper(freelyavailableonthewebsitesofPLoSMedicineat:http://www.plosmedicine.org/,AnnalsofInternalMedicineat:http://www.annals.org/,andEpidemiologyat:http://www.epidem.com/).InformationontheSTROBEInitiativeisavailableat:www.strobe‐statement.org.*Giveinformationseparatelyforexposedandunexposedgroups.

A P P E N D I X   (Continued)