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Table 1 Belief statements and sample quotes for each domain

From: Implementation of recommended type 2 diabetes care for people with severe mental illness – a qualitative exploration with healthcare professionals

Domain Specific belief Sample quote No. of participants Total no. of quotes
Behavioural Regulation I have a plan, either in my team or on my own, when managing diabetes in someone with SMI. "…within the CPA [Care Programme Approach] document there is a bit that is supposed to be filled in, I’d do a slightly different, what do you call it, aid memoir to go through [the Care Programme Approach document]. And on that I’ve got diabetes, exercise, diet, smoking, all of that, which I would see as part of that." 5 8
I review how I manage diabetes in people with SMI, and identify ways in which I can improve. "Diabetes is always on the agenda in teams and even the nurses meetings with, there was a presentation about one patient, one incident, someone had diabetes and how that should have been managed. So it’s always spoken about, our action plans, how should we manage it? How did we not manage it properly last time, and how should we improve? So that is always on the agenda for the nurses, yeah." 3 3
Beliefs about Capabilities I feel confident about managing diabetes in people with SMI. "[Managing diabetes in people with SMI is] …well, within the boundaries of what I can do." 9 10
Beliefs about Consequences If I didn't take steps to manage diabetes in someone with SMI, they would come to serious harm. “I think not until you’ve seen one of the worst cases of diabetes would you want to start taking it seriously. Because I think I have seen cases where people have had their legs amputated and it gets you back on your BM.” 13 22
Poorly controlled diabetes affects a person’s mental health. “One thing that’s very obvious from looking after mental health patients, there’s a definite correlation between high blood sugars and changes in their mental health state. There’s no question about it. It’s obvious. We’ve read about it. We’ve read all the research, when you’re looking after somebody. And it soon becomes very apparent to the ward staff. If they have someone whose sugars are high their mood is going to change. If their sugars are low their mood is going to change.” 9 9
Emotion Managing type 2 diabetes in people with SMI worries or concerns me. “For me I think [managing diabetes in someone with SMI] worries me in, it worries me, it does worry me, no, I’m concerned rather than worried to be honest.” 10 13
Managing type 2 diabetes in people with SMI frustrates me. “Well I suppose it can be frustrating for staff if people are, despite all the prompting and education, people just want to do their own thing, the patients say, well I don’t, I don’t really care actually, I don’t care what the long term consequence is, and I just want to have my cake today really, do you know what I mean, I suppose that can be a bit frustrating.” 3 5
Working with people with SMI scares me. “We’ve all got fear of mental health.” 1 1
Environmental Context & Resources I have access to a GP to help me manage diabetes in people with SMI. “…if anyone came here and had diabetes and there were issues I would just be picking the phone and calling the GP and saying, so and so is here, these are the problems, can they come and see you or book an appointment?” 13 31
More integrated IT systems would make it easier for me to manage diabetes in people with SMI. “Last week I think we spent nearly three of our days, our evenings catching up [the IT system] was down from a Thursday until Monday lunchtime so everything had to be backed up and then it’s got to be added on to [the IT system] and that has big consequences. Not only when that when you’re seeing that person because you’re limited on what information you can get. But it’s actually documenting for staff who have been on the ward over the weekend and can’t access. They haven’t got a care plan so they’ll ring me and say do you have the email of the care plan because we can’t access [the IT system].” 10 18
I don't have enough time to manage diabetes in people with SMI. “I think sometimes probably the resources, sometimes it can be very busy and very stretched and you may not have the time to dedicate and evaluate someone who’s very complex.” 10 15
I have access to someone with specialist mental health knowledge to help me manage people with diabetes and SMI. “I think more integrated working would encourage me, so at the moment we have a local enhanced service, it’s just local to [the area] where we have a CPN who comes in on a once every five weeks basis and does clinics here with her mental health patients and although I don’t see them with her jointly, the fact that she is in the building, we talk about other cases and that’s really handy.” 6 7
I have access to people with specialist diabetes knowledge to help me manage diabetes in people with SMI “…we have an excellent diabetic nurse actually, who’s so hard working and very proactive, and she will often email me if she’s concerned about a patient with a plan, she communicates very well, she emails the nurses, put it’s on [the IT system] and will make sure that I know and the ward doctor knows as well, so that the communication is very robust.” 11 27
Goals Managing patients' type 2 diabetes is as important as managing their mental health. “There is really no room for negotiation with that because if you’re looking after a patient you’re not only looking after the head or the brain but you’re looking after everything about them, about that particular patient. And with diabetes being one of them it’s just like vulnerability, you can’t take one and leave the other.” 5 7
Diabetes goals and targets need to be tailored for people with SMI. “You’ve got to set realistic goals not try and set goals that are not achievable because that’s setting people up to fail. So you have to tailor your goals and targets to that person sitting in front of you.” 5 6
There is a definite focus in my trust on managing type 2 diabetes in people with SMI. “…if you look at that teaching session that’s going on today down at [the hospital], physical health is much more on the agenda I think.” 4 5
I prioritise management of mental health over physical health in people with type 2 diabetes and SMI. “I think the risk is that very often the diabetes medication, because it isn’t an acute illness that has to be treated now, it’s something that sometimes gets left and just put on the back burner a bit while we maybe, let’s get the more psychologically stable first and then we can address the diabetes which very often might delay good treatment by years.” 3 7
Intentions I intend to follow NICE diabetes guidelines for patients who have type 2 diabetes and SMI “I’m going to refer her to get her DRI, the retinal screening done and I’m going to refer her to Desmond as well.” 2 2
Knowledge I do not know the guidelines, national or local, for managing type 2 diabetes. “I don’t think I’ve ever read the NICE guidelines [for diabetes]” 14 27
I know how to manage type 2 diabetes in people with SMI. “…when we trained I think our training was very, very helpful in the sense that we did what they called Project 2000, which meant prior to specialising in mental health you had to do all the other areas of nursing. So fortunately I was in A&E, diabetes was one of the things that people come with in A&E so I think my knowledge grew from them.” 7 13
Memory, Attention & Decision Processes Managing type 2 diabetes in someone with SMI is a routine part of my job. “Completely routine part of the job. As soon as you see somebody who has diabetes you begin that process of finding out what they’re taking, when they’re taking it, how well is it managed and who are they seeing.” 7 8
I tailor the treatment of type 2 diabetes in people with SMI depending on their needs. “…in the community is that treatment is very often tailored towards the mental health side. So we would be looking at things like risk. We would obviously follow NICE guidelines but we may have to tweak the NICE guidelines for issues like weight, risk of hypoglycaemia and the risk that somebody may be threatening suicide so we don’t want to give them any treatment that’s going to worsen.” 6 17
Optimism I am optimistic that I will be able to manage type 2 diabetes in people with SMI. “I’ve done it in the past, I’m doing it now, I’m certainly going to do it in the future, yeah.” 8 10
I do not feel optimistic about the health of my patients with type 2 diabetes and SMI “there’s no point in us thinking we’ve fixed them while they’re in hospital because once they’re feeling well, the same as all of us, once we’re well what do we do? We stop taking our medication.” 1 1
Reinforcement I would be disciplined if I did not manage type 2 diabetes in people with SMI “I think I’d be disciplined if I’m found to be negligent” 9 9
Incentives, such as CQUINS or QOF points, encourage me to manage type 2 diabetes in people with SMI. “For organisational reasons we as GPs are incentivised as QOF, quality outcomes from work so referring to diabetic education is a mandatory part of that. So we all do that anyway because we’re incentivised to.” 8 17
Skills Managing type 2 diabetes in people with SMI requires special communication and negotiation skills. “Yes, I do. I think you need to have a psychological, think, the way, think in a psychological way. So you mustn’t go, you mustn’t be in concrete. Why haven’t you gone to your retinal screening? You need to go, you could go blind is not going to work with someone who’s paranoid and doesn’t want to sit in a dark room with someone staring deeply into their eyes. It’ll just reinforce their fear and they’ll definitely avoid it and they won’t come and see you again. And I’ve seen patients who do that……So I think that everybody who works with this group of people should have some training in, I don't know, maybe not [motivational interviewing] because I think that’s probably too simple but more about trying to explore with them why it is that they haven’t done what it is that they should be doing.” 12 23
I need more training in diabetes in order to manage type 2 diabetes in people with SMI “Feeling I am purely a mental health nurse by profession so the little bit of general that I did I did a very, very long time ago. To be able to get updates and actually get more training to actually feel confident and there is now the training that was mentioned earlier in the office.” 9 21
Social influences I work as part of a team of healthcare professionals to help manage type 2 diabetes in people with SMI “…if I’ve got concerns about any cases, part of that clinical meeting is about bringing any concerns, so that could be either about somebody’s mental health or physical health or it could be a social issue that somebody’s experiencing. So I’ve got that avenue as well, so I can get other colleagues’ opinion, well I’ve dealt with that problem before so this is what I would do.” 15 36
Family members and carers help me manage type 2 diabetes in someone with SMI. “I suppose it depends on the family relationships, not everybody’s got a wonderful supportive family. Not everybody’s got a family that believe that mental illness exists and not everybody’s got a family that believe that diabetes is something that needs treatment. But I think when you’ve got that and you’ve got a patient who does have a level of awareness or a family member, definitely you use that.” 3 6
My patients' level of engagement is a key factor in how I manage their type 2 diabetes “I guess it’s challenging depending on where they are at that particular moment in time. So on admission if they’re manic you’re not going to engage. If they, by the time they’re leaving the ward and their anti-psychotic medication is working and they’ve got better insight then it’s going to be completely different. Absolutely different attitude altogether.” 16 69
Social Professional Role & Identity General practice should take overall responsibility for managing diabetes in people with SMI. “Because we’re in the community and the patients are supposed to be, in the community looked after by a GP, so I think the way services are set up is that yes, we can support, but I don’t, I think the identification and the continuous treatment and all that should really stay with the GP” 15 41
It is my responsibility to ensure that my service users with diabetes and SMI are able to access the relevant diabetes services. “They won’t routinely go for health screenings unless they are really pressed to do so. So, therefore, things can be missed so if we’re the only people they’re seeing, we do have a responsibility to make sure that at least we’re giving them some support to access services.” 12 22
I monitor, or help my patients to monitor, blood glucose levels in people with diabetes and SMI. “Well, obviously ensuring that they are taking, they’re having, they’re taking their whatever medicines it is for their diabetes, they’re compliant. We are supposed to be doing the, everybody that attends the clinic, doing regular blood sugar monitoring” 12 24
I support and advise my patients with diabetes and SMI to lead a healthy lifestyle. “But because we see them on a regular basis we can actually support them in attending their appointments and eating healthy and all that, yeah.” 11 25
All healthcare professionals are responsible for managing diabetes in people with SMI. “It’s everybody from social therapist, care assistants, anybody who has any contact. So their away day doesn’t start with nurses and registered nurses and managers and physical health leads. It starts with the people who are going to be on the ground. It could be the social therapist” 9 11
Mental health professionals have a responsibility to understand and monitor diabetes. “Well, the care coordinators but yeah, part of their role is to look at the total care of the patient. So they would obviously be expected to be aware that the client has diabetes. I think probably just monitoring that they’re taking medication and that they’re not particularly unwell through the diabetes” 8 13
Part of my role is to start new or step up the treatment of diabetes in people with SMI. “Well, within the boundaries of what I can do. I wouldn’t, I would never start people on anti-diabetic medication, I would never mess around with a diabetic management, because it’s not what I do on a day to day basis.” 6 8
I monitor diabetes medication adherence in people with diabetes and SMI. “Well, obviously ensuring that they are taking, they’re having, they’re taking their whatever medicines it is for their diabetes, they’re compliant.” 6 7
I monitor, or help my patients to monitor, blood pressure in people with diabetes and SMI. “…if I’m in a room that allows it, I will do things like blood pressure, weight, height, calculate BMI. All those sorts of things” 5 5
I monitor the weight of people with diabetes and SMI. “And I’m, so I’m going back to the depot clinic where we check weight, blood pressure, height, BMI and we are supposed to document new results.” 4 4
I assist my patients with diabetes and SMI to attend their diabetes appointments. “Well I guess recommending patients attend their annual physical health check to include blood sugar, is something that I do pretty routinely tell my patients so.” 4 5