Nurses' perception of preparedness for moving mental health care from psychiatric to general hospitals in Jamaica.

OBJECTIVES: To examine nurses' perception of readiness to care for patients with mental illness at two general hospitals in St. Catherine, Jamaica.
METHODS: This mixed-methods, cross-sectional study was conducted among nurses on the medical wards of two hospitals. A 39-item, self-administered questionnaire containing open- and closed-ended questions and personal interviews was used to assess the nurses' preparedness to care for mentally ill patients; their awareness regarding protocol for care of mentally ill patients; their attitudes towards the integration of mental health care into the general hospital setting; and any associations between these and select variables, e.g., education level, work experience; and perceptions of the integration process.
RESULTS: In all, 105 nurses completed the questionnaire (response rate: 80%) and six nursing supervisors were interviewed. Almost all (99%) felt the ward was unsuitable for admitting mentally ill patients; 95% felt inadequately prepared; and 73% were not aware that a standard management protocol for treating patients with mental illness was available. Staff training was deemed important. It was felt that a special area should be established for managing mentally ill patients.
CONCLUSIONS: The shift of mental health services was a strategic policy decision aligned with the recommendations and support of the Pan American Health Organization. This study shows the need for medication, equipment, implementation of standard operating procedures, adequate accommodation for patients, and staff trained to provide quality care for patients with mental illness.

Noncommunicable diseases (NCDs) are a major cause of the global burden of disease, of which neuropsychiatric disorders account for approximately 25% (1). According to the Global Burden of Disease Report 2016 (2), mental and substance use disorders are the largest group of diseases contributing to the non-fatal burden of disease (18.7%). In Jamaica, public health facilities treated almost 4% of the population for mental illness in 2015. The related, estimated costs for 2013 and 2014 were J$ 1.7 billion (US$ 13.3 million) in expenses and J$ 859 million (US$ 6.7 million) in lost productivity due to missed workdays. Trends point to future increases in both the number of individuals treated and the related costs (3).

There is a treatment gap between persons with mental disorders and the provision of care, especially in low- and middle-income countries (LMICs). In 2001, the World Health Organization (WHO) made 10 recommendations to reduce the treatment gap in mental health (4). One of these was shifting care from institutions to community facilities. Specifically, WHO recommended that, “large custodial mental hospitals…be replaced by community care facilities, backed by general hospital psychiatric beds and home care support, which meet all the needs of the ill that were the responsibility of those hospitals” (4).

Jamaica, a Caribbean island nation with a population of 2.9 million, is the third-most populous Anglophone country in the Americas (after the United States and Canada), and is considered to be a middle-income country (5). In 1972, Jamaica introduced the practice of treating some persons with mental disorders on the medical wards of general hospitals (5) Studies indicate progress, success, and even, superior outcomes in patients treated in the open medical wards versus those treated in acute psychiatric units and mental hospitals (5 – 7). Since 2000, there have been sustained, systematic efforts to shift care to the community and to integrate mental health into the primary health care setting. There are mental health beds in medical wards of general hospitals, and in 2017, data indicated that 74.5% of all psychiatric admissions in Jamaica occurred at such hospitals (8). High quality outcomes in psychiatric care in the general hospital setting are related to factors such as work environment, staffing complement, and level of training (9). Readiness for integration is influenced by perceptions of mental illness, structural conditions of facilities, drug availability, and health worker-derived stigma (10). Ascertaining readiness for integration and associated factors is implicitly important for the successful shift from specialized psychiatric hospitals to community/general hospitals.

Saint Catherine, a parish in south-east Jamaica, is one of the island's largest with a population of over 0.5 million. The objective of this study was to examine nurses' perception of the readiness to manage patients with mental illness at two general hospitals in St. Catherine, Jamaica.

MATERIALS AND METHODS

This was a mixed-methods study of convergent type with quantitative and qualitative components conducted from June – July 2017 at two general hospitals in St. Catherine. The hospitals were designated Hospitals A and B for the purposes of this study. The design was chosen to capture general trends and relationships, while simultaneously providing in-depth personal perspectives and gaining multiple pictures of the issue from several angles, including the nurses':

Self-reported preparedness to care for mentally ill patients;

Awareness of protocols for care of the mentally ill;

Attitudes towards integrating mental health care within the general hospital, and associations between these and select sociodemographic variables; and,

Perception of the process for integrating mental health care into the general hospital setting.

Study participants

The study population for the quantitative portion of the study was all 130 nurses, whether Enrolled Assistant/Certified Nursing Assistant (CNA) or Registered Nurse (RN), employed by two hospitals in St. Catherine, who had worked on the medical ward for at least 3 months during the 12 months prior to June 2017. Permission was obtained from the Nursing Office to distribute the questionnaire to each nurse during the change-of-shift meeting (2 pm and 10 pm daily); this time was chosen to minimize interference with usual duties.

In addition, purposeful, criterion-based sampling was used to select the nurses to be interviewed; the criterion was holding the position of Nurse Supervisor on a medical ward during the study period. Six nurses were interviewed, three from each of the two hospitals.

Data collection

Both quantitative and qualitative data were collected. Quantitative data were collected using a 39-item, self-administered questionnaire with closed-ended and Likert-Type questions (11). The instrument collected sociodemographic variables, in addition to education and training, awareness of management protocols for mentally ill patients, care-related safety issues, beliefs and attitudes regarding mentally ill patients, self-reported preparedness to care for mentally ill patients, and perceptions of suitability of the hospital facility for care of such patients.

The qualitative portion of the study sought to explore nurses' views on mental health care in general hospitals. The criterion of holding the position of Nurse Supervisor was assumed to give these nurses a broad knowledge of related issues and challenges. Interviews with six nurses explored views of the integration process, readiness for the process, and associated concerns. The interviews were recorded.

Data analysis

Quantitative data was entered, coded, and cleaned using IBM SPSS Statistics software, version 17 (SPSS Inc., an IBM company, Chicago, Illinois, United States). Descriptive statistical summaries were generated and appropriate statistical tests applied; P values of ≤ 0.05 were considered statistically significant. The qualitative data was subjected to framework (thematic) analysis involving transcription familiarization, charting, and interpretation (12). Qualitative data, through merging and comparison, was used to corroborate and elucidate quantitative findings.

Ethics

Permission to conduct the study was obtained from the University of the West Indies Ethics Committee (Kingston, Jamaica), the South East Regional Health Authority (Jamaica) and the relevant hospital authorities. Informed consent was obtained from participants. Two boxes were provided on the wards by the researchers; one for signed consent forms, and the other, for completed questionnaires; this separation maintained anonymity.

RESULTS

The study was conducted at two hospitals designated Hospital A and Hospital B. A total of 130 questionnaires were distributed at both hospitals; 105 were completed and returned (10 refused to participate and 15 were not completed by the cut-off date). The overall response rate was 80% (105/130); Hospital A had a response rate of 83% (33/40), and B, 80% (72/90).

Sociodemographic profile

Table 1 shows the participants' sociodemographic data. All were Jamaican nationals and females, from 23 – 54 years of age, with a mean age of 35.4 years ± 8.2 years.

TABLE 1

Sociodemographic profile of 103 nurses surveyed in a study of their perception of readiness for shift from psychiatric hospital to general hospital psychiatric care in St. Catherine, Jamaica, 2017

Variable		Total	Hospital A		Hospital B		P valuea
			n	%	n	%
Age in years
	n	95	26		69
	Mean and standard deviation	35.4 ± 8.2	35.8 ± 7.5		35.2 ± 8.6		0.711
	Range	23 – 54	25 – 54		23 – 54
Gender (n = 103)
	Female	103	33	32.0	70	68.0	–
	Male	0	0	0	0	0
Highest education level attained (n = 105)
	Diploma (Enrolled/Certified Nursing Assistant)	20	7	35.0	13	65.0	0.747
	Bachelor of Science in Nursing	69	20	29.0	49	71.0
	Postgraduate degree/certificate	16	6	37.5	10	62.5
Years of work experience in nursing (n = 103)
	1 – 5	42	12	28.6	30	71.4	0.982
	6 – 10	31	9	29.0	22	71.0
	11 – 15	20	7	35.0	13	65.0
	16 – 20	7	2	28.6	5	71.4
	21 – 25	3	1	3.3	2	66.7
Months worked on medical ward (n = 88)
	1 – 3	16	6	7.5	10	62.5	0.291
	4 – 6	27	8	29.6	19	70.4
	7 – 9	20	8	40.0	12	60.0
	10 – 12	25	4	16.0	21	84.0

P value based on independent t-test. All other P values are based on chi-square tests or Exact tests as appropriate.

Educational levels were categorized into diploma (Enrolled/CNA), Bachelor of Science in Nursing (BScN/RN), and postgraduate certificate/degree. Overall, by their highest level of education, 16 respondents (15.5 %) had a post-graduate certificate/degree; 69 (65.7%) had a BScN; and 20 (19%) had diplomas. There was a positive, moderate, and significant correlation between years of experience and educational level; as years of experience increased, educational level also increased (Spearman's rho = 0.562, P = 0.001). Of the total respondents, 89 (84.8%) had not completed any postgraduate training.

Both Hospitals A and B had the plurality of respondents with work experience within the 1 – 5-year range (41%). This was followed by the 6 – 10-year range, with 30% and 29% of respondents having over 10 years of service. Throughout the year, nurses are rotated to other wards or areas to gain experience. The respondents' time worked on the medical ward ranged from 3 – 12 months, most frequently 4 – 6 months and 7 – 9 months.

Readiness and preparedness

The majority of respondents (95%) at both hospitals did not feel adequately prepared to care for mentally ill patients, with 101 nurses (99%) reporting that the setting was not suitable. A safety room to house a patient who is acting out, endangering others or him/herself, was reported as not being available by 93% (n = 98) of the nurses; 6% (n = 6) were not sure; and 1 % said such a room was available. Emergency plans to be activated in times of crisis or for dealing with a patient acting out were not in place according to 61% of respondents. In-depth interviews revealed that nurses felt that the facilities were not prepared to admit mentally ill patients; and that there should be a special area for the mentally ill with guard rails, away from patients with medical conditions.

Medication availability and patient management

When asked about the availability of drugs and equipment to care for mentally ill patients, the responses varied according to hospital, with Hospital B generally having a better supply. Fifty percent (n = 52) of nurses indicated that they were very familiar with the medications used in the care of the mentally ill; however, of those only 44% (n = 23) said the medication was available on the ward at both hospitals (P > 0.05). During the in-depth interviews, nurses agreed that the supply needs to be more reliable since sometimes these medications are out of stock. Equipment, such as restraints, is not always available, and the respondents have had to improvise with gauze or similar, which is not always adequate.

The standard management protocol for the care of the mentally ill patient is a document prepared and distributed by the Ministry of Health of Jamaica (13). In all, 76 respondents (73%) were not aware of a standard management protocol, with only 27% reporting that they were aware of this document (Table 2). This policy/protocol was not seen on the ward by the six Nurse Supervisors who were interviewed; five were not sure if one existed at all. One Nurse Supervisor noted that she had the chance to read the protocol for the care of the mentally ill patient in the primary care setting, but had not seen it in the hospitals.

TABLE 2

Nurses awareness of standard management protocol for management of mentally ill patients by hospital in St. Catherine, Jamaica, 2017

	Aware		Not aware		Total
	n	%	n	%	n	%
Hospital A	9	28	23	72	32	100
Hospital B	19	26	53	74	72	100
All	28	27	76	73	104	100

χ2 (1) = 0.00; P = 1.

Attitudes

Attitudes toward delivery of mental health care services and treatment of the mentally ill patient in the general hospital setting were examined using Likert-style questions. Select summaries are shown in Figure 1.

FIGURE 1

Attitudes and perceptions regarding aspects of mental health care in a study of nurses' perception of readiness for shift from psychiatric hospital to general hospital psychiatric care in St. Catherine, Jamaica, 2017

Table 3 presents bivariate analyses of the relationships between these attitudes and educational level, years of nursing experience, and time worked on medical wards in the prior 12 months. There were statistically significant associations between educational level and attitudes towards treating mentally ill patients in the general ward and care of the mentally ill as being an important role of the nurse, respectively. As educational level increased, so did the proportion displaying positive attitudes. As time worked on the medical ward increased, so did the percentage disagreeing that it was adequately prepared. No other significant associations were identified.

TABLE 3

Attitudes by highest level of education, years of nursing experience, and time worked on medical wards in the past year among participants in a study of nurses' perception of readiness for shift from psychiatric hospital to general hospital psychiatric care in St. Catherine, Jamaica, 2017

Variable		n	Highest education level attained (%)			n	Years of nursing experience (%)					n	Months on medical ward (%)
Mentally-ill should not be nursed on general ward		105	Diploma	BScN	Post-graduate	103	1 – 5	6 – 10	11 – 15	16 – 20	21 – 25	88	1 – 3	4 – 6	7 – 9	10 – 12
	Strongly disagree/disagree	31	55.0	24.6	18.8	30	21.4	38.7	35.0	14.3	33.3	26	31.3	29.6	40.0	20.0
	Undecided	10	5.0	13.0	0.0	10	14.3	9.7	5.0	0.0	0.0	8	18.8	7.4	5.0	8.0
	Strongly agree/agree	64	40.0	62.3	81.3	63	64.3	51.6	60.0	85.7	66.7	54	50.0	63.0	55.0	72.0
	P valuea			0.038b					0.706					0.631
Caring for mentally–ill patients: important part of nurse's role		102				100						85
	Strongly disagree/disagree	6	21.1	3.0	0.0	6	2.4	10.0	10.5	0.0	0.0	6	0.0	7.7	15.0	4.2
	Undecided	9	0.0	10.4	12.5	9	9.8	13.3	5.3	0.0	0.0	8	13.3	3.8	15.0	8.3
	Strongly agree/agree	87	78.9	86.6	87.5	85	87.8	76.7	84.2	100.0	100.0	71	86.7	88.5	70.0	87.5
	P value			0.043b					0.793					0.517
Have skills to work with mentally ill patients		102				101						85
	Strongly disagree/disagree	51	50.0	51.5	43.8	51	57.1	55.2	30.0	42.9	66.7	43	35.7	44.4	60.0	58.3
	Undecided	16	0	20.6	12.5	16	16.7	20.7	5.0	14.3	33.3	15	14.3	22.2	15.0	16.7
	Strongly agree/agree	35	50.0	27.9	43.8	34	26.2	24.1	65.0	42.9	0.0	27	50.0	33.3	25.0	25.0
	P value			0.130					0.081					0.707
Restraints must be used for all mentally -ill patients		105				103						88
	Strongly disagree/disagree	79	85.0	73.9	68.8	77	69.0	80.6	70.0	85.7	100.0	68	81.3	66.7	85.0	80.0
	Undecided	9	5.0	11.6	0.0	9	14.3	6.5	5.0	0.0	0.0	9	12.5	14.8	5.0	8.0
	Strongly agree/agree	17	10.0	14.5	31.3	17	16.7	12.9	25.0	14.3	0.0	11	6.3	18.5	10.0	12.0
	P value			0.306					0.875					0.820
Nurses adequately prepared for integration of mental health care into general hospital		103				102						86
	Strongly disagree/disagree	76	84.2	67.6	87.5	76	76.2	66.7	85.0	71.4	66.7	63	46.7	63.0	80.0	95.8
	Undecided	15	5.3	17.6	12.5	14	11.9	20.0	0.0	28.6	33.3	12	26.7	18.5	10.0	4.2
	Strongly agree/agree	12	10.5	14.7	0.0	12	11.9	13.3	15.0	0.0	0.0	11	26.7	18.5	10.0	0.0
	P value			0.335					0.330					0.015b

All p-values based on Fisher's exact test.

Statistically significant at 0.05 level.

Challenges and possible solutions

The nurses also shared some recommendations on workable solutions to some of the challenges they are facing in the health care system. Figure 2 outlines three main themes—preparedness for integration, patient care, and participant recommendations/solutions—and sub-themes that emerged, with the interrelatedness of subthemes indicated by the arrows.

FIGURE 2

Diagram of three main emergent themes and sub-themes in a study of nurses' perception of readiness for shift from psychiatric hospital to general hospital psychiatric care in St. Catherine, Jamaica, 2017

The nurses spoke passionately about staffing issues. This was a major concern for the Nurse Supervisors, who reported staffing has implications for the quality of care and that there is a general shortage of nurses in the health care system. They also felt that the staff should have some specific mental health training prior to initiation of the integration process.

DISCUSSION

The finding that the majority of the respondents hold a BScN as their highest educational attainment, coupled with the relatively few years of experience, suggest that nurses working on the medical wards are junior nurses. As they gain experience, they are promoted to senior positions away from bedside nursing on medical wards or they are moved to specialized units, such as maternity, accident and emergency, surgery, and sometimes, to supervisory positions. The loss of more senior, experienced nurses from direct bedside nursing leaves the junior nurses with little direct supervision in patient care. Loss of senior nurses from bedside nursing is also the result of migration to other jurisdictions that offer better compensation packages and work environments (14). This creates a decreased workforce to adequately care for the volume of patients seeking care at the general hospital. Limited human resources result in inadequate mental health care (7). Abel and colleagues posit that greater emphasis needs to be placed on training specialized mental health nurses (7).

This current study has shown that almost 85% of respondents had not completed a post graduate training program of any type. Our results revealed that attitudes toward mental health care on the general wards is positively related to educational level. So too is the perception of the role of the nurse as important to caring for the mentally ill. Training is thus of paramount importance. The training of nurses to deliver a wide range of mental health services can help to address the lack of human resources in this area. Additionally, continuous training of health care workers is needed to develop and reinforce skills (7).

Most respondents reported not being adequately prepared to care for the mentally ill on the general wards. Reasons given were inadequate setting, lack of training, shortage of staff, and lack of equipment and drugs for the care of these patients. Therefore, as indicated by previous studies (15, 16), there is a need for training and education to improve nurses' knowledge and confidence when caring for patients who are mentally ill. There is concern whether patients will receive necessary and quality care given the limited human and material resources available.

Interestingly, nurses who had spent more time on the medical ward were more likely to report that nurses were inadequately prepared for the integration of mental health care into the general hospital setting. We posit that longer exposure increases the appreciation of the challenges presented by the shift of care and greater realization of the degree of inadequate preparation.

A WHO report (17) states that the mental health unit in the Ministry of Health of Jamaica develops mental health standards, creates mental health policies, and reviews and monitors mental health programs in the country. These policies are distributed to the clinical areas where they are utilized in the daily management of patient care. However, this policy/protocol document had not been read by the majority of our study respondents. It is important that the document be available to instruct the users how to proceed in specific situations. Its use is critical to the development of mental health services and systems, and its reported absence by nurses is of concern. These policies guide mental health care and facilitate the provision of psychotropic drugs, and treatment in the community and at general hospitals (5). Without this, there is potentially greater indifference, inconsistency of action, and legal risk.

Studies done in Jamaica have indicated that the care outcome of patients with mental disorders treated in the open medical ward can be superior to those treated in specialized acute care psychiatric units and mental hospitals (6). Required drugs and equipment are necessary to facilitate effective nursing care. Abel and colleagues (7) state that in order to reduce the burden and treatment gap associated with mental disorders, there must be adequate financing. A budget oriented towards treating mental health problems will determine the extent to which a country can effectively implement and sustain mental health policies, programs, and services. Noting that in many countries in Latin America and the Caribbean, disproportionate spending on specialized psychiatric hospitals continues, the Pan American Health Organization (PAHO) has urged increased efforts towards decentralization of mental health services (18). This, however, cannot occur in a vacuum and requires strategic approaches that recognize critical elements for success, including preparedness for integration, addressing patient safety issues, and providing appropriate staffing.

Nurses do and will play important roles in the realization of the shift of psychiatric care to general hospitals. Consequently, the expressed concerns, perceptions, and challenges are germane to this process. Incorporation of in-service clinical attachments in psychiatry can help increase nursing knowledge and competence (19). The innovative use of psychiatric nursing aides may partially alleviate shortages of fully trained nursing personnel (20). Findings from this Jamaican study argue for Member States to reflect on and appraise the extent to which such issues are given attention. There is a need for further studies that explore the facilitators for hospital implementation of mental health care policies.

Limitations

This study was conducted in two hospitals in one parish in Jamaica—its findings cannot be generalized to all such hospitals given the variations in staffing, range and level of services, infrastructure, and drug availability. The study was not longitudinal; therefore, trends cannot be assessed. Nurses interviewed were from a single, geographic area, and their views and experiences may not span the gamut of existing views and experiences.

Conclusions

There should be an increase in post-basic psychiatric training of nurses in general hospitals to increase mental health care skill and competency. This should be accompanied by adequate supervision of personnel by staff specifically trained in mental health care and the distribution of mental health care policy and protocol documents to staff. Staffing levels should be bolstered, at least initially, through the use of psychiatric nursing aides. Facility infrastructure and drug and equipment availability must be improved to enhance patient management. Bi-annual or annual audits of hospitals by the Ministry of Health/ Regional Health Authority to assess gaps in the mental health patient care delivery process should be conducted. Though not generalizable, the lessons learned from this study may be instructive to others working in resource-limited areas in Latin America and the Caribbean.

Nursing staff are at the frontline of care for mentally ill patients admitted to the general wards where they provide 24-hour care. The shift of mental health services to the general hospital setting was a strategic move by the health authorities of Jamaica, consistent with the PAHO vision. This move, however, must be supported by the supply of drugs and equipment, implementation of standard operating procedures and protocols, adequate accommodation for patients, and specialized staff training. Without these, the benefits of the shift of care from the psychiatric hospital to general hospital are unlikely to be fully realized.