|Year : 2022 | Volume
| Issue : 2 | Page : 184-189
Impact of mental health first aid training for primary health care nurses on knowledge, attitude and referral of mentally ill patients
Sreevani Rentala1, Sunanda Govinder Thimmajja2, Savitha S Vasudevareddy3, P Srinivasan4, Mahesh Desai5
1 Professor & Head, Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neuroscience, Dharwad, Karnataka, India
2 Assistant Professor, Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neuroscience, Dharwad, Karnataka, India
3 Principal, SJM Institute of Nursing Sciences, Chitraduraga, Karnataka, India
4 Nursing Tutor, Department of Psychiatric Nursing, College of Nursing, All India Institute of Medical Sciences, Patna, Bihar, India
5 Director, Dharwad Institute of Mental Health and Neuroscience, Dharwad, Karnataka, India
|Date of Submission||12-Jul-2022|
|Date of Decision||08-Dec-2022|
|Date of Acceptance||13-Dec-2022|
|Date of Web Publication||31-Dec-2022|
Dr. Sunanda Govinder Thimmajja
Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neuroscience, Dharwad - 580 008, Karnataka
Source of Support: None, Conflict of Interest: None
Increasing prevalence of mental illnesses worldwide, nurses' competence and preparedness in addressing patients' mental health needs urgent particular attention. However, nurses who receive general nursing training may have inadequate knowledge and beliefs about mental health disorders. The aim of this study was to examine the effectiveness of short-term in-service training programme on improving nurses' knowledge and attitude related to prevention and first aid management of mental illnesses. A quantitative, quasiexperimental one group pre- and post-test design was carried out at a tertiary mental healthcare setting, Karnataka, with the sample consists of 50 registered nurses working at primary healthcare centres and Taluk hospitals located in North Karnataka, India. The results indicate a significant increase in the nurses knowledge (t =−15.70, P < 0.001) and favourable attitude (t = −2.63, P = 0.01) regarding the prevention and first aid management of mental illness among community. There was also a significant improvement in the referring of the cases to mental health care settings at 1 month after attending short-term in-service training programme on prevention and first aid management of mental illness.((t = −14.23, P < 0.001). The study concludes that well-designed in-service training programme for a nurses not only improves the knowledge and attitude of the nurses but also improves referrals of the mentally ill patients to higher centres.
Keywords: Attitude, effectiveness, first aid management, in-service training, knowledge, mental illnesses
|How to cite this article:|
Rentala S, Thimmajja SG, Vasudevareddy SS, Srinivasan P, Desai M. Impact of mental health first aid training for primary health care nurses on knowledge, attitude and referral of mentally ill patients. Indian J Cont Nsg Edn 2022;23:184-9
|How to cite this URL:|
Rentala S, Thimmajja SG, Vasudevareddy SS, Srinivasan P, Desai M. Impact of mental health first aid training for primary health care nurses on knowledge, attitude and referral of mentally ill patients. Indian J Cont Nsg Edn [serial online] 2022 [cited 2023 Feb 3];23:184-9. Available from: https://www.ijcne.org/text.asp?2022/23/2/184/366608
| Introduction|| |
Mental health conditions are common and are the leading cause of disability worldwide. Statistics suggest that every sixth Indian needs mental health help. Almost 8% of people in the state of Karnataka have a mental illness. Mental disorders are more prevalent in the 30–49 years of age group or over 60; low income is linked to the occurrence of mental disorders and urban areas were most affected. The systematic review conducted among primary level workers for the care of people living with mental disorders revealed that the gap between those who require and could benefit from mental health interventions and those who actually receive such care is very large. One of the major reasons attributed to such a wide treatment gap is the problem of inadequate resources. In India, inadequacy exists in infrastructure as well as in human resources.
Despite improvements in various health indicators, India contributes disproportionately to the global burden of disease. A large proportion of the population ends up impoverished because of high out-of-pocket healthcare expenditures and suffers the adverse consequences of the poor quality of care. Task-shifting to non-specialist community health workers has been recommended as an effective strategy for the delivery of efficacious treatments in low-resource settings. Community care settings of India are the prime locations where in 2017 up to 197.3 million people had mental disorders including the majority (45.7 million) diagnosed with depression followed by anxiety disorders (44.9 million). Integrating psychiatric and mental health services into general medical services are needed, so that general hospitals will provide combining services. In developing countries with acute shortages of mental health professionals, the delivery of mental health services through the general health care is the most viable strategy. This increases access of underserved populations to mental health care. Major difficulties frequently encountered in integrating psychiatric services to general services are planning and training of human resources for providing care. Furthermore, mental disorders and physical health problems are closely associated and often influence each other. Despite the availability of effective mental health treatments, these interventions are rarely employed in a coordinated approach in routine care to yield long-term improvement in mental health outcomes.,,
In general, primary healthcare providers face many barriers to refer patients to speciality mental health settings. Hence, patient uptake to these offsite referrals remains low.,,,,
Among patients with access to primary care who are accurately diagnosed with depression, fewer than 15% receive adequate treatment to achieve remission. Furthermore, physicians, physician assistants and nurses often lack the time or training to effectively address mental health needs.
The health care staff require training in basic mental health competencies in order to detect mental disorders, provide basic care and refer complex cases to specialist services; and mental health specialists need to be equipped to work collaboratively with general health care staff, and provide supervision and support.
The balanced care model suggests that, in low-income countries, the available mental health provision should be invested in nurses at primary health care and community settings. The roles of these nurses include case finding and assessment, brief counselling and psychosocial and pharmacological treatments. There is now emerging evidence that this approach can be a cost-effective method to provide treatment and care for people with mental illnesses. However, training alone is insufficient, and it is increasingly clear that ongoing supervision is likely to be necessary to support staff to begin to apply the guidelines and to gain and maintain clinical competence. The costs of such supervision, therefore, need to be included in the core resources necessary to make community care sustainable. A study conducted on mental health educational programmes for general health professionals stated that the lack of mental health education training and preparation of general health professionals was the most identified barrier in meeting mental healthcare needs of patients. Hence, it is recommended to conduct and provide special training programmes on selected mental health care modules to enable general health professionals to provide better care in meeting the needs of mental health patients. Given the high prevalence of mental health problems globally, there is a need for proper training which is to be given to non-mental health trained professionals, and primary care nurses to identify and manage mental health problems by filling the treatment gap in mental health practice.
Aim of the study
The aim of the present study was to examine the effectiveness of short-term in-service training programme on improving nurses' knowledge and attitude related to prevention and first aid management of individuals with mental illnesses and referral of mentally ill individuals.
| Methods|| |
This study used a quantitative approach with a quasi-experimental one-group pre and post-test design. The study was carried out in a tertiary psychiatric care setting, Karnataka, India between February 2019 and April 2019. The sample consists of 50 registered nurses working at primary health care centres and Taluk hospitals located in North Karnataka, India. The sample size was arrived from the previously conducted study on mental health training where the effect size for knowledge was d = 1.32 and for attitude d = 0.60 calculated by paired t-test between pre and post-test scores. Based on which G * Power was used to estimate, the sample size and the required numbers were 39. The treatment facilities available at primary health care centres and Taluk hospitals were diagnosis, treatment for minor mental illness, and referral services. Inclusion criteria were as follows: (a) registered nurses, (b) with a minimum of 1 year of experience in a primary health care centre or Taluk level hospital, (c) willing to participate and (d) able to understand and speak the Local and English language.
The demographic information included gender, age, education, qualifications, type of hospital working in and total years of experience in nursing. Structured questionnaire on knowledge and attitude regarding prevention and first aid management of mental illnesses were used to collect the data from participants. These scales were developed by the investigators for the purpose of the present study. The knowledge on prevention and first aid management of mental illnesses questionnaire consists of 25 multiple choice questions categorized under 2 subheadings: (1) Knowledge on causes, signs and symptoms of mental illnesses-7 questions and (2) Knowledge on prevention and management-18 questions. Each correct answer was scored as 1 and incorrect as 0 with the total score ranging from 0 to 25. A higher score denotes higher knowledge. The attitude questionnaire on first aid management of mentally ill individuals consists of 24 items categorized under three subheadings. (1) Attitude on causes of mental illnesses-7 items, (2) Attitude on signs and symptoms of mental illnesses-6 items and (3) Attitude on the prevention and management of mental illnesses-11items. Participants were asked to respond on a 4-point Likert scale about whether they 'do not agree' to 'completely agree'. Each item was given a score of 0 to 'do not agree', and 4 for 'completely agree'. The total score ranges from 0 to 96. Higher scores reflect a positive attitude while lower scores reflect a negative attitude. The test-retest reliability coefficients were calculated for both the questionnaires by administering the same instrument repeatedly to 15 nurses at a 2-weeks interval. The reliability coefficients for the knowledge and attitude scales were 0.85 and 0.82, respectively. Content validity for tools and intervention program was established by taking opinions from five experts. Referral of mentally ill individuals was collected by verifying hospital records.
In-service training program
This program was conducted under the scheme 'Development of Nursing Service-Training of Nurses' and the fund was released from the Ministry of Health and Family Welfare, Govt of India. Participants were invited to the in-service training program (A total of 42 h, 6 h per day for 7 days). The program was conducted in two batches each batch consisting of 25 nurses. A structured teaching plan for in-service training was developed in line with the institution policy, expert panel's opinion and literature review regarding prevention and first aid management for individuals with mental illnesses. The training program focused on both theoretical classes and practical demonstrations like history taking, process recording, mental status examination, case presentations and discussions in the wards and also given a assignments as a re-demonstrations of cases. The training programme was implemented by lecture cum demonstrations and group discussion by using appropriate teaching aids along with clinical postings. The theory sessions were dealt by a multidisciplinary team of mental health includes, psychiatrist, psychiatric nurse, clinical psychologists and psychiatric social work specialist. Theory classes were focused on the concepts of mental health and mental illnesses, signs, and symptoms, early recognition, therapeutic modalities in the management of mentally ill individuals, mental health care facilities available and the role of a nurse in the prevention of mental illnesses. Teaching was done using lecture method, group discussion and case demonstrations. Participants were posted in psychiatric wards, every day for 3 h, where they were demonstrated mental status examination, history collection, symptom identification, basic counselling techniques, relaxation techniques and group therapy.
Participation was voluntary and written informed consent was obtained from the participants. The study protocol was approved by the Institutional Ethics Committee.
Data collection procedure
Investigators sent the requisition to general hospitals and primary health centres for deputing the nurses to short term in-service training programme. The sixty nurses' were recruited from primary health centres and Taluk hospitals located in Northern state of Karnataka, India, among 50 nurses were selected for the study based on inclusion criteria and divided them in to two slots for undergoing training. The written informed consent was obtained from the participants before collecting the data. Before commencement of in-service training, the participants were pre-tested to assess knowledge and attitude by administering self-instructed questionnaires. Later participants underwent 7 days training programme. On the 17th day, the post-test was conducted by using same questionnaires. The case referral details (1 month referral details) were collected from hospital records after 30 days of training. Nurses referred cases through their medical officer to nearest district hospital and mental health care centres.
The data were analysed using the Statistical Package for the Social Sciences version 22.0 (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). Data were checked for normality by the Shapiro − Wilk test and found that all the outcome variables including knowledge, attitude and referral were normally distributed but the demographic characteristics such as age in years and years of experience were non-normally distributed. Accordingly, descriptive statistics were used to describe demographic variables. A paired t-test was used to compare pre and post-mean knowledge, attitude and referral scores.
| Results|| |
Nurses' demographic and professional characteristics
A total of 50 nursing professionals participated in the study; among the majority (72%) were females. The median age of the nurses was 33.50 years (IQR = 28–42.25) and the median years of clinical experience was 9.00 years (IQR = 2.75–16.50). The majority (68%) of the participants had completed general nursing and midwifery course, 22% were post-graduate nurses and remaining 10% were graduate nurses. Thirty (60%) nurses who participated in the study were selected from general hospitals and the remaining 20 (40%) were from primary health centres. Among 50 participants only 4 (8%) reported that they had undergone mental health training programs organized by their respective district mental health authority [Table 1].
Impact of training programme
The paired t-test was applied to test the effectiveness of the training programme. There was a statistically significant improvement in nurses' knowledge, attitude, and the number of patients referred to psychiatric care settings between pre and post-test scores. After the training, the mean knowledge score significantly improved from 16.80 (standard deviation [SD] =2.60) to 22.42 (SD = 3.33) which was statistically significant at a 0.05 level of significance (t=-15.70, P < 0.001). A paired sample t-test demonstrated significant improvement in area-wise nurses' knowledge scores between pre and post-test scores. The mean knowledge score on causes, signs, and symptoms component had significantly improved from 5.92 (SD = 0.94) to 17.42 (SD = 2.36) which was statistically significant at a 0.05 level of significance (t = −41.02, P < 0.001), and the prevention and management component of knowledge did not have any statistically significant improvement [Table 2].
After the training, the mean attitude score significantly improved from 60.88 (SD = 11.49) to 65.64 (SD = 10.79) which was statistically significant at a 0.05 level of significance (t = −2.63, P = 0.01). With regard to components of attitude, the mean attitude score of the signs and symptoms component was significantly improved from 13.88 (SD = 3.92) to 15.40 (SD = 4.31) which was statistically significant at a 0.05 level of significance (t = −2.06, P = 0.04), and the mean attitude score on prevention and management of mental illness component was also significantly improved from 29.00 (SD = 6.20) to 31.58 (SD = 5.91) which was statistically significant at a 0.05 level of significance (t = −2.60, P = 0.01). No significant difference was found in the component of attitude on causes [Table 3].
Further, with regard to the referral of mentally ill patients to psychiatric care settings, the mean referral score improved from 0.28 (SD = 0.78) to5.02 (SD = 2.20) in the post-training assessment which was statistically significant (t = −14.23, P < 0.001) at a 0.05 level of significance [Table 4].
|Table 4: Comparison of pre- and post-test number of mentally ill individuals referred to psychiatric hospitals n=50|
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| Discussion|| |
Mental illnesses cause substantial challenges to healthcare professionals worldwide. Increasing prevalence of mental illnesses worldwide as well as the nurses' competence and preparedness in addressing patients' mental health needs urgent attention. However, nurses who receive general nursing training may have inadequate knowledge and beliefs about mental health disorders. The present study aimed to examine the effectiveness of short-term in-service training programme on improving nurses' knowledge and attitude related to the prevention and first aid management of mental illnesses. The overall results indicated that there was statistically significant improvement in nurses' knowledge scores t = −15.70, P < 0.001. The present study findings were supported with some of the previous literature findings. These findings were similar to the study conducted on mental health training with regard to knowledge among non-mental health professionals where the knowledge score significantly increased after the mental health training programme with a large effect size (P < 0.001, d = 1.32). However it is worthwhile to notice that improvement in knowledge was not significant in terms of management. Future training needs to incorporate this factor and plan for sessions on management based on learning needs.
In the present study there was a statistically significant improvement in nurses' favourable attitude (t = −2.63, P = 0.01) regarding prevention and first aid management of mental illnesses. This result was supported by a previous study, which aimed to enhance knowledge, skill and attitudinal change among general health practitioners, who undergone mental health education program. Further, the findings were supported by the study conducted on attitude among non-mental health professionals revealed that the attitude score significantly increased and improved the favourable attitude after the mental health training with a large effect size (P = 0.039, d = 0.60).
The present study results also proves that significant improvement (t = −14.23, P 0.001) in referring the cases to psychiatric care settings after attending short term in-service training programme on prevention and first aid management of mental illness. The significant knowledge gained on causes and signs and symptoms could be attributed to it.
Similar studies previously done supports present study results that, in-service nursing education programs improves the self-reported practice scores and work efficiencies among nursing staffs at different fields.,
| Conclusion|| |
The study finding concludes that well-designed in-service training program for nurses not only improves the knowledge and attitude but also improves in referral data of the mentally ill patients to higher mental health care centres. Findings highlight the need to provide an in-service training program regarding mental health first aid management for nurses' in general health care settings. Study recommends that encouraging the primary health nurses to attend regular in-service training programs with a focus on identifying early signs of symptoms of mental illness, providing first aid management and prompt referrals to higher centres will improve mental health care at remote levels.
Limitations of the study
The study reports and recommendations are limited to the participation of short term training program so the 1 week training program cannot be a substitute for comprehensive training programmes such as diploma in psychiatric nursing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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