Defining obsessive compulsive disorder
Obsessive compulsive disorder (OCD) is considered to afflict 1-4% of the population in their lifetime, with little variation in gender or geography (National Institute for Health and Care Excellence (NICE), 2005), and regarded as one of the six most common mental health problems in the UK (Baker and Kirk-Wade, 2024). It is characterised by recurring unpleasant thoughts that result in repetitive activities which interfere with service users' daily activities. While factors such as depression, anxiety, history of trauma and family history of OCD may increase risk factors, the cause of OCD remains unknown (Wagner, 2023). Linde et al (2022) discussed how OCD can be caused by complex factors such as genetic, biochemical and environmental variables. It is suggested that behaviours associated with OCD develop in adolescence or early adulthood, becoming more apparent in individuals as they mature (Linde et al, 2022). Breaking the sequence of obsessions and compulsions can be difficult and cause heightened feelings of anxiety and fear, especially because these behaviours often develop as a technique to relieve discomfort. OCD manifests itself in a variety of ways and goes beyond the prevalent idea that it is as simple as hand washing or checking the door is locked. Although these are legitimate OCD compulsions, these beliefs fail to understand the intense thoughts that precede these acts, as well as the problems that constant compulsions can cause.
Increasing prevalence of OCD
Literature suggests that diagnosis of OCD is increasing (Abramson and Feusner, 2023). In fact, Atladottir et al (2015) discovered an average increase of 332.7% in a 10-year period in European countries. Cunning and Hodes (2021) identified that the COVID-19 pandemic played a significant part in worsening OCD symptoms. During this time the public was urged to engage in cleansing routines in accordance with World Health Organization (WHO) COVID-19 recommendations. These guidelines may have increased symptoms of anxiety associated with fear of contamination, thus intensifying the compulsion to clean for those with OCD.
Symptoms like irritation, anxiety and low mood, once primarily associated with OCD sufferers encountering perceived contamination, are now increasingly reported by individuals without any prior mental health diagnosis. (Khosravani et al, 2021). Abramson and Feusner (2023) identified that diagnoses have increased since the 1990's, most likely because of easily accessible information, which has led to more awareness of the condition. Mental health professionals are also better equipped with identifying this condition and its subtypes.
Social media is now readily available on most household technology devices, with 5.04 billion people around the world using online platforms (Kemp, 2024), which may have influenced the prevalence of OCD. Mental health self-diagnosis content on social media has become increasingly popular (Dewak, 2023), potentially leading to misdiagnosis and overdiagnosis of mental health conditions. Thombs et al (2019) described overdiagnosis as the phenomenon of people being diagnosed with mental health conditions when they have mild symptoms that do not require medical attention. Nonetheless, social media platforms have created an online community more inclusive and supportive of mental health, destigmatising many mental health conditions, including OCD.
Individuals with OCD frequently experience shame because of rumination and self-criticism over undesirable obsessions and recurring routines (Laving et al, 2023) and these emotions may lead to delay or avoidance of diagnosis or treatment for fear of judgement. With increasing prevalence of the condition, it is pertinent that district nurses develop an understanding and awareness of OCD to tailor their healthcare approach.
Working with patients with OCD
There are many sub-types of OCD, each characterised by different obsessions and compulsions. However, the main indicator of the condition across all sub-types is the need to control obsessions that trigger feelings of anxiety, which are followed by compulsions to ease the distress. As a district nurse Apprentice, the author of this article has cared for many service users with OCD and experienced their need for control. This control manifests in a variety of situations such as frequent requests to remove shoes or wear shoe protectors, repeatedly checking whether the anticoagulant injection has been expelled correctly before and after administration, and a service user ordering more than £500 000 worth of stock through her GP because of a fear of running out.
It can be particularly difficult to provide care to a patient with OCD due to barriers such as embarrassment, fear of judgement, hospitalisation, or criminalisation (Robinson et al, 2017). Experiencing a lack of control over one's own body, medication, and care may contribute to this anxiety, given that OCD is linked to a desire for control, presenting as a further barrier to accepting nursing interventions (Moulding and Kyrios, 2007). While many district nurses care for service users with OCD, there is no guidance or training delivered on how to provide effective holistic care to these patients. The Royal College of Nursing (2023) found that 49% of nurses feel ill-equipped to care for patients' mental health while tending to their physical needs, identifying inadequacies in pre- and post-registration training. Education on the subject is heavily reliant on the nurse having prior experience with OCD or using their professional curiosity to educate themselves on the condition by their own means. However, a lack of appropriate guidance and training may lead to a misunderstanding of the needs of service users and potentially increasing their feelings of anxiety.
It is important for nurses to accept their patient's anxiety, routines and other compulsions without condemnation. Individuals with this condition may feel ashamed or embarrassed by their obsessions and compulsions, so patience and understanding are imperative in such situations. While there is no cure for OCD, therapy and medication are considered the best practice (NICE, 2005). Building therapeutic relationships with individuals could be beneficial to identify the trigger for their behaviour and work together to discuss ways to reduce them. A therapeutic alliance between a healthcare provider and a service user has a profound influence on health outcomes on someone with mental health problems (Hartley et al, 2020). In the case of district nursing, having the same nurse attending to the service user could help with maintaining familiarity and consistency and develop a sense of rapport.
Public Health England (2016) introduced the Making Every Contact Count approach in 2008, which encourages interactions between healthcare professionals and service users to help improve their physical and mental health and wellbeing. Designed to last for only a few minutes, this quick and simple approach could be beneficial to improving outcomes for service users with OCD on a local level. During a district nursing encounter for a physical health need, this intervention could assist in recognising symptoms of OCD, increasing motivation to engage with treatment, or identifying any risk of harm.
OCD and health inequality
Individuals living with mental health conditions tend to have high morbidity and mortality rates (Makurah, 2018). Physical wellbeing is reduced in those with OCD (Pozza et al, 2019), with approximately 50% experiencing ill health from medical diseases (Aguglia et al, 2018). Social inequalities such as poverty, unemployment, stigma, discrimination and social isolation drive health inequalities (Public Health England, 2018). The Marmot Review (2010) identified trends between health inequalities and social inequalities, setting out clear policies to be implemented at a local and national level to assist in reducing health inequalities. Marmot (2020) investigated changes 10 years following the initial review and found inequalities in life expectancy had in fact increased. Despite this, there has been no national health inequalities policy set by the national government since 2010, and currently no plans have been made to address the matter. The NHS Long Term Plan (2019) identifies health inequalities as a major contributing factor to ill health, addressing the variation in holistic wellbeing dependent on socio-economic differences. While the preventative activities outlined in the plan are critical to addressing health inequalities, the emphasis on specific diseases and habits ignores health disparities caused by multiple comorbidities and unhealthy behaviours. To ensure change, the progress on the plan regarding health inequality will be dependent on overall government effort and the effectiveness of local partnerships.
People with OCD are found to be more socially isolated than the general population (Wagner, 2023). This may be because of shame associated with unwanted thoughts and behaviours that defy societal norms. Social isolation and physical ill health have been closely linked (Leigh-Hunt et al, 2017), evidencing that individuals with OCD are potentially more vulnerable to experiencing health inequalities. This social isolation may contribute to difficulties forming relationships, causing individuals to experience feelings of loneliness, anxiety, depression and low self-esteem. Wagner (2023) wrote that these feelings influence suicidal thoughts, while studies have shown that the possibility of suicide was increased tenfold in someone with OCD when compared to the general population (Fernández de la Cruz et al, 2017; Benster et al, 2022). District nurses and all healthcare providers should be committed to improving the outcomes during every contact with their service users, identifying limitations to holistic wellbeing and recognising the risk of suicide.
Working with the multidisciplinary team
Löyttynena et al (2023) noted that district nurses, as experts in public health nursing, play a crucial role in managing and preventing mental illness, therefore knowledge regarding mental health conditions is pertinent in the district nursing profession. However, people with OCD may not reach out for care for their mental health difficulties, but may attend services for their physical health needs. As district nurses are often the first port of call, identification, opportunistic assessment and management may offer crucial assistance to those with OCD. Approximately one out of every eight individuals, or 970 million people worldwide, are living with a mental health condition (WHO, 2022). Despite this, there is very little training delivered to the district nursing workforce to ensure they are equipped to deal with many mental health conditions. Moreover, even though there is a strong association between mental and physical illness, services continue to work independently from one another. To guarantee the best outcome for service users, a multidisciplinary approach is required to deliver integrated person-centred care.
Multidisciplinary teams have previously been beneficial in many circumstances, such as with people with complex needs and young offenders (Baxter et al, 2023). However, in recent years, service users being discharged from hospitals, those in the community at high risk of poor health and social outcomes and the elderly residing in residential care have benefited from the collaborative work of the multidisciplinary teams (WHO, 2022). The three core principles for a multidisciplinary team to work effectively are identifying clear objectives, working closely with effective communication and implementing regular meetings (West, 2021). Gaps in knowledge regarding mental health for district nurses may be addressed by working collaboratively within these teams and initiating regular training sessions and meetings to be able to identify needs and care for service users with mental health conditions.
Information governance would be required when district nurses collaborate with the multidisciplinary team. Service users requiring treatment from district nurses may not be known to other services, despite professional opinion being that mental health input may be beneficial. Clear information sharing permission would need to be obtained to be able to discuss care. It is important to not make assumptions that the service user is already known to mental health services, or that they would consent to their information being shared.
Initiating change
Change and improvement is essential to the healthcare system to address the needs of the service users and integrate new evidence and more efficiency to deliver high-quality and holistic care. Dickson et al (2020) compared the leadership role of a district nurse to a conductor of an orchestra; demonstrating the variety of techniques they used in the various roles they played. There has been progress in meeting the physical health needs of people in mental health settings (Royal College of Nursing, 2023), however, district nurses must address gaps and irregularities when providing care to service users with mental health conditions. With the specialist knowledge and skills district nurses have acquired, initiating and implementing change to practice could be hugely beneficial for service users with co-existing OCD and physical ill health.
The NHS Change Model (NHS England, 2012) was developed to address the constraints of existing frameworks for planning, initiating, and maintaining both large and small changes within the organisation. It aims to include the most crucial features of existing models in a way that is tailored to the NHS's specific needs. It draws on evidence-derived methods and ideas from many domains, including organisational development, management and leadership. In their evaluation of The NHS Change Model, Martin et al (2013) found the framework to have a great possibility in promoting advances in healthcare during a time when the necessity for change is vital.
Using the model to develop a multidisciplinary team for the coordination of care for service users with OCD could increase the accessibility of appropriate services and improve the effectiveness of care delivery to individuals. A successful multidisciplinary for this condition would consist of district nurses, GPs, mental health nurses, psychiatrists and social workers. The model places emphasis on the need of creating a common purpose for success and aligning values. Identifying common goals and values and achieving a shared understanding can help to break down barriers, bringing groups of stakeholders together for a shared objective.
Regular meetings similar to the Gold Standard framework (2024) meetings may be beneficial to both the service user and the health care professionals within the multidisciplinary team. The Gold Standard framework meetings provide updates on the condition of palliative patients to the relevant health care providers and how to effectively support the patient at home (Haraldsdottir et al, 2014). Shaw et al (2010) found that patients receiving care from providers using the framework had improved outcomes, more access to specialised assistance and more responsive care.
Clinical governance
Applying a multidisciplinary approach to meet the needs of service users with OCD conforms to the clinical governance framework. The seven pillars of clinical governance include varying elements of patient care which assists, preserves and improves the quality and safety of treatment. Each pillar is used to achieve innovation and clinical excellence within the organisation. Barriers to clinical governance in practice may involve resistance to change and time constraints from stakeholders, inadequate organisation and poor inter-professional relationships. Nevertheless, as set out by the Nursing and Midwifery Council Standards for Competence (NMC, 2010), nurses must initiate and maximise opportunities to improve services. Additionally, success could transpire with good leadership, shared values and using the NHS Change Model.
Conclusion
People with OCD may hesitate to approach healthcare services for their condition or feel a sense of embarrassment when approaching services for treatment. District nurses play an important role to support such service uses and should be vigilant for indications of the condition. Building therapeutic relationships is paramount when delivering care, which helps in ensuring that the right steps have been taken to contribute to the holistic wellbeing of the service users. Mental health conditions such as OCD contribute to health inequalities, and despite data demonstrating this, there has been very little change targeted at reducing disparities. As there is no evidence to suggest changes are anticipated at a government level, local level changes may help to improve the lives of individuals with OCD. By working closely within the multidisciplinary team, knowledge and skills regarding the condition, evidence regarding how to manage, and referral to services with the consent from the service user would benefit the health outcome and holistic wellbeing of service users with OCD.