Training General Nurses in Mental Health Assessment Using GMHAT/PC in India

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Training General Nurses in Mental Health Assessment using GMHAT/PC in India

Steven Jones, Paul Keenan, RajgopalRajendra, Vijay Danivas,

Murali Krishna

Background

Training of Indian general nurses in a hospital setting required the structure offered by the Global Mental Health Assessment Tool (GMHAT) that would provide a framework to underpin mental health assessment training. Attitudes of those undertaking the training and current levels of knowledge and awareness to mental health issues was explored prior to any training occurring in the use of GMHAT, that we considered fundamental to good mental health practice. The training of general nursing staff within large general hospitals provided a starting point for mental health care to be considered, as physical caretasks often took priority above all other responsibilities. Our project aim was to train nursing staff and nurse trainers in mental health assessment using GMHAT. From the total nurses trained in GMHAT we selected 40 mental health champions in a train the trainers approach. It was important that this training did not become a stand-alone,one off delivery but that it was cascaded and sustainable.

The project team consisted of two senior UK mental health staff and two hospital psychiatrists from Mysore. The context from outset was to ensure cultural awareness and sensitivity. Initially the project examined increasing rates of suicide in India, specifically Southern India and the demands placed upon Intensive care beds through deliberate pesticide ingestion. Exploring this issue, highlighted certain needs, preventative work, stigma, attitudes, shame, religion and it is still illegal in India to attempt suicide. It was important to examine the needs of Indian nurses and attitudes towards those with mental illness and especially those who have attempted to harm themselves. This scoping was undertaken prior to any training package being implemented. So even before education commences a lot of ground work had to be completed, this was staged approach that kept patient centred care and cultural awareness at the core.

Relationships with hospital managers and directors were established and shared aims identified. The initiative did not want to present any impressions that is was educators outside of India advising, that this is how it should be done; but rather,It was important to build and develop relationships and this continued at every stage of the project, to keep senior managers appraised. The project team were acutely aware of senior manager’s support for this project at every stage which was as important as nursing staff identifying the need to provide mental health care. In addition we carried out research into staff education and attitude baselines before implementing any training. The approach was what can we learn from each otherand take from an Indian context and apply to the UK, and vice versa. Both healthcare cultures share similar issues in staff education, the importance of time to attend training, clinical credibility of educators, learning approaches, making the training practical that meets clinical needs of staff, and therefore patients. Irrespective of country, barriers would be physical nursing care duties having more significance that psychological ones. Staffing levels for example on wards provided challenges to every day care, staff rotations throughout hospital wards every 3-6 months impacted on continuity.

Improving awareness in general nursing staff

Recognising any deficits in care is a first step to improving qualityand also that it is the domain of nurses to care holistically for patients and families. The identification and exploration of mental illness in society and the attitudes of health care professionalswas addressed. Openness by staff on the subject of psychiatry is a good first step. We also learnt from the pilot training that delivering lectures and lecturing styles towards staff was not the best way of skill equipping them, small group work, case studies, and practice within the sessions worked better. Learning styles varied and had to be adapted for UK staff as well as Indian nurses.

The benefits of improving psychological care have to be considered. From a patient perspective care is enhanced and moves towards holistic provisions if it includes the ward team and families. This is vital as families are the main source of support on discharge towards patients, with a paucity community resource. Addressing the shift in a culture or society is perhaps ambitious, but steps must be taken towards this goal and interventions have to start somewhere.

Time constraints are important to address in training, considering staff motivation levels, levels of clinical supervision for example may assist in this. The concept of clinical supervision in the hospitals we worked at was not undertaken due to lack of time, and senior nurses did not receive clinical supervision beyond job appraisal systems. This is another area that requires consideration if nurses are to remain effective and valued in their role. Appraisal systems operate but should be separate to a clinical supervision system. The role and status of nurses in the team has to be raised, and not just that of physical task completers. That talking to patients and families is as important as undertaking medicine rounds for example, perhaps both can be completed together. The therapeutic value of conversation and acknowledgement offers worth and mental health care is not the sole domain of psychiatric inpatient units.

Teaching a subject is a process that has to managed, adapted, and followed up in the departments with staff and managers. Approaches have to work at grass route ward level and have senior managerial support with ever increasing pressures on resources; these tensions apply throughout healthcare irrespective of continent, but are perhaps more acute in India.

Attitudes explored before training delivered

Training general nurses in mental health assessment is not a new concept, but transferring content from the classroom can be challenging; for example, obstructions to effective intervention, including difficulties in following western models to understand these behaviours and some unfavourable attitudes of health care professionals towards those who self-harm 1,2,3.Unfavourable attitudes among doctors and nurses can impact negatively on patient care and treatment4,5,6.Nurses were identified for training in GMHAT as they have the highest level of daily contact with mental health patients and their families. Therefore, their attitudes and knowledge about mental illness can influence their willingness and ability to deliver interventions effectively 7,8

Identifying and reducing stigma from nurses must form the foundations before any educational training on mental health assessment can be undertaken. Whilst carrying out the projects in India, we have explored care and treatment of patients’pre and post hospital care. In India and many other countries, mental illness is heavily stigmatised and for future projects we would like to explore prevention work, for example, in schools and community groups (Indian schools for example during exams age 14 self-harm rates increase)We also recognise now that aftercare is very limited after hospital discharge (for example there is no/ limited community mental health teams in India). It is our aim to link now with NGOs, such as the ASHA workers (Who we have met and developed links with in Mysore) to develop these ideas into community settings.

Practical Issues

The right knowledge, skills and attitudes are thecornerstone of good mental health care.It is perhaps too convenient to carry out physical health care tasks and neglect uncomfortable psychological support, but nursing should provide holistic care for patients and their families, and physical care alone will not do that. Nurses and the hospital team can also play a crucial role in mental health promotion and improvements.

On line materials have been useful for some nurses trained, but internet and computer access within Indian hospitals for nurses was difficult. The team did underestimate the low provisions of IT and internet access throughout both hospitals, and mental health assessment systems (GMHAT/PC) have been paper based and integrated into patient case notes. There are no electronic patient records systems in both hospitals.

Benefits

GMHAT provided a framework not only to structure the training but a very useful validated tool that could be used immediately on return to practice areas. GMHAT allowed for knowledge and attitudes to be explored during the training and presented opportunities to explore beliefs that might be conducive to more positive mental health outcomes. We also sought to build relationships with psychiatry, facilitating the opportunityfor general nurses to receive feedback from visiting Psychiatrists, building skill competence, confidence. We strived to embed mental health assessment into general ward culture, change some attitudes, and develop an interest in psychiatry were psychological skills are brought up alongside physical skills. We aimed to make small progressive changes, and a train the trainers approach seemed the best way to approach this. This training has already led to an increase by 63% in referrals directly to the departments of psychiatry, thus nursing practices have clearly changed (Jones et al, 2015). The direct referrals are also a testimony of their growing role and leadership in mental health and the improved relationship between staff at the general hospital and psychiatry, which has opened referral routes directly from nurses to doctors. It is these direct gains that were not initially envisaged that helps embedding the project within two general hospitals. But the UK for example also has lessons to learn from India, and whilst the training off staff, custom and practice and setting may differ; the issues are similar and both can learn from each other. We will be seeking to explore the training in India within UK hospital for both cultures to learn from.

We are sure that staff attending from the UK jointly training with Indian colleagues gave the project some impetus and credibility. Equally we are convinced that without Indian staff being involved at every stage of the project and in joint training then this would not have worked, local knowledge was key in this work. This also provided onsite support for consultation and continued support for general hospital staff, and the appointment of a research assistant and collator of all the assessment undertaken buy nurses over both sites provided rich data. Systems to collate learning evaluations, audit of patient assessment are essential to chart project effects.

Sustainability challenges

The trainers that carry out mental health training on a rolling monthly rota, and educational clinical staff access in Mysore have been enhanced by local project staff access. The project administration support post employed to undertake ‘ audit and evaluation’ ensures data is captured, sessions are planned, staff have a central point of contact, that also supports project staff in the UK and India. Ongoing evaluation help to ensure that the training remains clinically credible and teaching materials and learning styles are reviewed and adapted.

Wages are poor in India for nurses and training often competes with staffing wards and department needs. The support of senior managers, senior clinicians across both hospitals has been commendable. However, both hospitals have limited resources and funding for metal health care and it might be worth considering for future projects some financial incentives for staff who train others. This has been discussed with hospital directors who have skilled staff who could train other hospital staff. This would assist in disseminating to the training, raising the issue of mental illness and suicide intervention as well as income generating. This approach serves all agendas with this significant public health issue.

We trained 40 trainers to disseminate the training throughout both hospitals. The trainers were senior nursing clinicians that are ward and collage of nursing based. However, trainers who worked at a ward level were seldom able to leave the word rota to deliver training. Only nursing staff that were not ward based such as community and nursing college staff could commit to regular sessions, a position not dissimilar from the UK.

A Web based learning platform was developed in support of the package, but this was used by nurses on their mobile devices and from home settings. We did not anticipate limited computer access at a ward level, and training materials and GMHAT had to be paper based. Then the information gathered is inputted onto GMHAT PC following assessment, but this does add duplication and more time to assessments. The use of IPADS for each ward setting is being explored but also highlighted that private assessment and interview rooms are also lacking. This did highlight the need to be flexible and problem solve as the project developed In many ways addressing practicalities such as these on the training is as essential as skills equipping.

Conclusions

Stigma, stereotypes, and negative attitudes toward medical and psychological conditions are a major impediment in the provision of healthcare; such attitudes can have a direct impact on patients’ well-being and the type of health care they receive 9Trained nursing staff (and therefore student nurses on placement) may hold unhelpfulpre-conceived beliefs and values that are cultivated in the working environment 10It is important for mental health practice to examine these attitudes, beliefs, and perceptions about mental health and the need to treat patients individually, not just in India but in other continents. Culturally sensitive interventions that respect staff beliefs and attitudes must also balance against the needs of the patient and their immediate family. Implementing clinical supervision systems in support of educational initiatives may further assist in this endeavour. Developing a strategy and targeting resources must be given serious consideration and goals should be specific, measureable, achievable, realistic and targeted that facilitate development of care pathways to be operationalised into practice.

Mental health assessment and principles of treatment must consider the scope of cultural sensitivity in India, and time for staff on the wards is a premium. The first aim of this study was to identify the issues for future initiatives, nurses forwarding that patients need counselling, psychological support and identify those needs, but acknowledge that they do not have the practical skills, or confidence to be able to deliver them consistently 8Furthermore, negative attitudes for people who have psychological disabilities and will impact on their lifestyle options, educational and vocational opportunities, quality of life and a decline in community participation (10). Communities, of which hospital are very much part of in India, can play a critical role in mental health awareness and reduce the burden of disease. They can provide social support to vulnerable individuals, engage in follow-up care, fight stigma and support those bereaved by suicide11.

References

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2.Bose, A., Konradsen, F., John, J., Suganthy, P., Muliyil, J., and Abraham, S. (2006). Mortality rate and years of life lost from unintentional injury and suicide in South India. Tropical Medicine International Health, 11, 1553- 1556.

3.Gunnell, D., Eddleston, M., Phillips, M. R., and Konradsen, F. (2007). The global distribution of fatal pesticide self-poisoning: systematic review. BMC Public Health, 7, 357.

4.Ouzouni, C and Nakakis, K. (2009). Attitudes towards attempted suicide: The development of a measurement tool. Health Science Journal; 3:222–31.

5.Christison G.W and Haviland M.G (2003). Requiring a One-Week Addiction Treatment Experience in a Six-Week Psychiatry Clerkship: Effects on Attitudes Toward Substance-Abusing Patients. Teach Learn Medicine, 15(2):93-97

6.Kumar, N., Rajendra, R., Sumanth, M.M., Krishna, M., Keenan, P., Jones, S. (2016) Attitudes of general hospital staff towards patients who self-harm in South India: A cross-sectional study. Indian Journal of Psychological Medicine. In press Nov 2016.

7.Anderson M, Standen P, and Noon J. (2003). Nurses’ and doctors’ perceptions of young people who engage in suicidal behaviour: A contemporary grounded theory analysis. International Journal of Nursing Studies; 40: 587–97. [PubMed: 12834924].

8.Jones, S., Krishna, M., Rajendra, R., and Keenan, P. (2015)Nurses attitudes and beliefs to attempted suicide in Southern India.Journal of Mental Health.24(6) 423.

9.Link B.G, Struening E.L, Rahav, M, Phelan J, C, and Nuttbrock, L. (1997). On Stigma and its Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnoses of Mental Illness and Substance Abuse. Journal of Health Social Behaviour, 38(2):177-190.

10.Gething, L. (1992). Nurse practitioners’ and students’ attitudes towards people with disabilities. Australian Journal of Advanced Nursing, 9(3):25-30.

11.World Health Organization. (2014). Preventing suicide: A global imperative. WHO.