Recovery from ‘schizophrenia’: Perspectives of mental health nurses in the Eastern island of Indonesia

Abstract

Background

Recovery is a way of life to make people’s lives more meaningful by working and interacting socially in the community. The recovery has become a new vision of mental health services, including in persons with schizophrenia. However, this concept is relatively new and still limited to nurses in developing countries, such as Indonesia. Several studies among nurses related to this topic have been conducted in the Western part of Indonesia. Yet, no studies have been implemented in the Eastern part of Indonesia. Therefore, exploring nurses’ perspectives in the Eastern island of Indonesia is necessary to provide a complete understanding of recovery in patients with schizophrenia.

Objective

To explore the perspectives of mental health nurses on recovery from schizophrenia.

Methods

This was a qualitative study using a phenomenological design. The study was conducted from April to May 2020 at community health centers in Maluku, Indonesia. Eight nurses recruited using purposive sampling participated in in-depth interviews. The interviews were audio-recorded, transcribed verbatim, validated, and analyzed based on Colaizzi’s method of data analysis.

Results

Five themes were generated, including (i) treat a patient like a brother, (ii) recovery as an unfamiliar term with various meanings, (iii) medication as the primary action but also the main problem, (iv) being recovered if referred to a mental hospital, and (v) ineffective mental health programs.

Conclusion

The findings of this study can be used as an input and evaluation for nurse managers to make an effort to uniform the perception among nurses in Indonesia regarding the recovery process in schizophrenia. It is also suggested that community health centers leaders and mental health policymakers prioritize and optimize recovery-oriented mental health programs and services in the Eastern island of Indonesia. Additionally, the findings offer new insight about ‘we are brothers’ or called ‘hidop orang basudara’, which is expected to be one motto for nursing care in Indonesia and beyond.

Globally, the concept of recovery has become a national mental health policy in most developed countries, such as England, Wales, and the European Union, and has brought significant changes to the mental health system (Jacob, 2015). The concept of recovery was proposed by Anthony (1993) as a new vision in the practice of mental health services. This vision requires healthcare workers to empower patients, with all their limitations, to live optimally and productively. However, this is relatively new and is still limited to healthcare workers, especially nurses in a developing country like Indonesia.

Nurses as healthcare workers and at the forefront of service delivery have essential duties and responsibilities. The nurse’s perspective on recovery is critical for improving mental health practice and quality of life for patients with schizophrenia. The important role of nurses in the recovery process is to accompany and teach patients to recognize the disease they are suffering from, build personal identity, regain the meaning of life, and maintain it so that they can function socially in society (Drapalski et al., 2012). Thus, nurses are not responsible for the fulfillment of daily life. But how to be a resource provider, supporter, and encourager of patients to manage their condition by providing trust, fostering a sense of responsibility, and motivating them to believe that they can recover (Suryani, 2013).

The contribution of nurses to mental health services can bring about a change in mindset, which based on evidence, recovery is not a treatment but a way of life to make patients’ lives more meaningful by working and interacting socially in the community (Shepherd et al., 2012; Suryani, 2013). The proper perspective on recovery must be owned by the nurses in charge of the mental health program at community health centers in Indonesia. However, research conducted to build the understanding of nurses in charge of mental health programs regarding recovery from schizophrenia in Indonesia is still limited. For example, Agustina et al. (2019) also examined the experience of nurses in charge of psychiatric programs at community health centers in carrying out recovery at Cimahi, Indonesia. In addition, Nurjannah et al. (2019) examined the views of health workers on schizophrenia recovery in the community health center, Yogyakarta, Indonesia. Purbaningsih (2019) explored the perspectives of patients, families, professionals, and policymakers regarding recovery in schizophrenia in Cirebon City, and Tania et al. (2019) investigated the experience of health cadres in supporting the recovery process of people with mental disorders in the Cimahi City, Indonesia. However, these studies were conducted only in the Western part of Indonesia; there has been no research on recovery in patients with schizophrenia clients in Eastern Indonesia. This is a gap that needs to be filled up. Therefore, this study aimed to explore the perspectives of mental health nurses regarding schizophrenia recovery in the Eastern island of Indonesia.

Overview of Health Care System in Indonesia

Indonesia consists of three levels of the health care system: primary level, secondary, and tertiary level. Primary health care is mainly given in community health care centers (called Puskesmas) and village health posts (called Pustu) where most facilities are community-based and provide primary health care and prevention programs (Gunawan et al., 2020). Public and private hospitals provide the secondary and tertiary levels of health care. All of these levels are designed for universal health coverage in Indonesia.

Indonesia, officially the Republic of Indonesia, consists of 17,508 islands geographically located in Southeast Asia, between the Indian and Pacific oceans (Gunawan et al., 2020). Indonesia is also called the republic of multiculturalism, influenced by Mainland China, the Middle East, the Indian subcontinent, Europe, and Austronesia (Stone et al., 2016; Central Intelligence Agency, 2018; Gunawan et al., 2020). Indonesia has multiple religions, 300 ethnics groups, and 700 local languages, including the Maluku language (BBC News, 2018; Central Intelligence Agency, 2018). All Indonesians are united by Pancasila (as the national philosophy based on belief in God, humanism, unity, democracy, and justice) and one language (Bahasa Indonesia) (Gunawan et al., 2020).

Health development in the Indonesian region is divided into Western and Eastern parts of Indonesia (Gotama et al., 2019). The Western part of Indonesia consists of Java, Sumatra, and Kalimantan islands, while the Eastern part of Indonesia consists of Sulawesi, NTT, Papua, and Maluku (Gotama et al., 2019). The development gap between the two regions is relatively straightforward, which can be seen from the transportation facilities, road infrastructure, hospitals, health service facilities and infrastructure, the number of professional health workers, and the communication system (Gotama et al., 2019). The Eastern part of Indonesia has a small population compared to the Western part of Indonesia, but a significant obstacle is an unevenly distributed population, some of whom live in the mountains or islands (Gotama et al., 2019). This condition affects various public services, one of which is health services. Health service problems in Eastern Indonesia, such as (1) primary health care in the border, remote, and archipelago regions are still low, (2) transportation facilities are very limited with high costs via land, rivers, sea, and air, (3 ) low access to health services, (4) the number of nurses is sufficient when viewed from the needs, but the services are only waiting for the arrival of patients, (5) the acquisition of drugs is generally not in accordance with demand, and (6) health equipment, health support facilities at the Puskesmas are insufficient (Suharmiati & Astuti, 2013). Therefore, with this condition, it is necessary to explore the nurses’ perspectives in taking care of patients, particularly in understanding recovery in patients with schizophrenia in the Eastern island of Indonesia.

Overview of Mental Health Programs at Puskesmas in Indonesia

The total number of Puskesmas in Indonesia is 10,063, higher than the total number of hospitals, 2,844 (Ministry of Health of Indonesia, 2019a). Mental health services at Puskesmas are contained in the Regulation of Law No.18 of 2014 concerning mental health (Ministry of Law and Human Rights, 2014), Permenkes No.75/2014 on Puskesmas, and Regulation of Law No.2/2018 on Minimum Service Standards (Sardjoko et al., 2018). The Government of Indonesia, through the Ministry of Health, seeks to encourage services for those who experience mental disorders, such as controlling pasung problems (seclusion, restraint, and isolation of people with mental health disorders), equitable distribution of mental health resources, online services through mental health applications and strengthening promotive, preventive, curative, and rehabilitative efforts at the Puskesmas level (Ministry of Health of Indonesia, 2018). Although the programs are not yet optimal; however, Puskesmas has become an essential key to equitable mental health services. It is also recommended by World Health Organization (2013) in the Mental Health Action Plan 2013-2020 program to move mental health services from institutions/hospitals to the community.

Methods

Study Design

This study employed a phenomenological approach as outlined by Colaizzi (1978) to explore nurses’ perspectives on recovery in schizophrenia. Using this design was in congruence with the purpose of this study, which enables researchers to put aside their perceptions of a phenomenon and give meaning to a participant’s experiences.

Setting and Participants

This study was conducted from April to May 2020 in eight Puskesmas at Buru District, Maluku, Indonesia. Eight nurses were involved in this study selected using purposive sampling. The inclusion criteria of the participants were a nurse who has experience in taking care of patients with schizophrenia (at least for six months), a registered nurse with minimum Diploma III, and those who were able to communicate and agreed to join the study.

Data Collection

Data were collected using in-depth interviews. Each interview was conducted face-to-face at a meeting room in each Puskesmas ranged between 45 and 60 minutes per session and audiotaped to ensure that all spoken words were captured. The participants were initially asked with an open-ended question, “what do you think about the recovery process of patients with schizophrenia?” and continued until the data reached saturation or no new data were identified. The interviews were conducted by the author (FAT) in a local language, the Maluku language.

Data Analysis

Data were analyzed by content analysis model using Colaizzi’s method of data analysis with the following steps: (1) each transcript was read and reread to obtain a general sense about the whole content, (2) extracting significant statements for each transcript that pertain in this study, (3) formulating meanings from these significant statements, (4) sorting the formulated meanings into themes, (5) integrating the findings into an exhausting description of the phenomenon in this study, (6) describing the fundamental structure of the phenomenon, and (7) validating the findings (Colaizzi, 1978). All data analysis was conducted in the Indonesian and Maluku languages and translated to English for publication only. The translation version of the results was ensured to have the same meaning as the original data and confirmed by English editors and nursing experts.

Rigor

The rigor of this study was ensured using a peer-checking method by an independent auditor or an expert/a professor in qualitative research who evaluated and systematically analyzed all data as well as compared and contrasted data quality, transparency, and interpretations. In addition, member-checking was also done to confirm the findings to avoid bias or imagination from the researchers.

Ethical Considerations

This study was ethically approved by the Faculty of Medicine, Padjadjaran University, Indonesia, with an approval number of 291/UN6.KEP/EC/2020. Prior to data collection, each participant signed written informed consent and was informed about the aim of the procedure of the study. Each participant could withdraw from the study without any penalties. The researchers guaranteed that all data were kept confidential.

Results

Characteristics of the Participants

The participants in this study consisted of four males and four females, with ages ranging from 24 to 46 years. Most of the participants have working experience as nurses in charge of mental health programs ranging from 8 months to 14 years. In addition, most of them hold a Diploma III nursing background. Diploma III refers to a three-year nursing program at the college/university level. In contrast, Bachelor/Ners degree refers to a five-year program that consists of 3.5 years of an academic program and 1.5 years of professional program (Gunawan, 2019).

Table 1.

Participants’ characteristics

Participants	Age (Year)	Sex	Educational background	Work experience (Year)	Length of work as a nurse in charge of a mental health program (Year)
P1	44	L	DIII	14	14
P2	35	L	DIII	10	1.4
P3	40	P	DIII	11	9
P4	24	L	DIII	2.5	1
P5	35	P	DIII	12	1
P6	28	L	Bachelor+Ners	4	2
P7	46	P	DIII	12	1
P8	32	P	Bachelor+Ners	7	8 months

Analytical Findings

Five themes developed in this study, including (1) treat a patient like a brother, (2) recovery as an unfamiliar term with various meanings, (3) medication as the primary action but also the main problem, (4) being recovered if referred to a mental hospital, and (5) ineffective mental health programs. These themes are illustrated below with exemplars from the participants’ stories using pseudonyms for the participants.

Theme 1: Treat a patient like a brother

This theme describes the expressions of the participants regarding their calling as nurses in the form of sincerity, serving with hearts, and treating a patient like a brother. For example, one participant states, “I treat the patient like my brother” (P4). Another participant expressed similarly, “Running this program should be from the heart. If we use our heart, we will treat patients with love like our own family” (P1); and, “The program has merged with me, I consider the patients as human beings who must be cared for and treated like other normal humans” (P1).

Other participants also explained further about their calling as nurses to care for patients sincerely. P8 said, “Being a nurse is my calling to care. So, whatever the task to serve people with mental disorders, I still have to do it sincerely” (P8). In addition to sincerity, sacrifices are also needed in serving patients. The participant expresses it, “We need to be sacrificing for the patient because there are several times (outside of office hours), there are families of the patients come and call me at home” (P8).

In addition, this finding also revealed support from family, neighbors, and the community in patient recovery. Participants told about the family’s concerns in caring, such as taking the patient to the Puskesmas, paying attention to the patient’s hygiene, and monitoring the medication. The participant said, “Hidop orang basudara [we are brothers]. If he gets sick, we also get sick…Moluccan people say that potong di kuku, rasa di daging [a wound at the nail is felt throughout the body]” (P1).

Hidop orang basudara [we are brothers] has been ingrained from generation to generation as one of the wealth and strengths of the Moluccans. This principle views all humans, including patients, as brothers and sisters. Whatever the circumstances, good or bad, a brother must give his best to support his brother. The slogan potong di kuku, rasa di daging [a wound at the nail is felt throughout the body] describes what nurses think about the patients’ experiences.

Similar to what was said by P1, another participant also said, “The family support is good; they can receive well” (P7). Furthermore, he said, “His family took him to the Puskesmas; saw and took care of his personal hygiene, such as bathing, and so on (P7)”. In the same context, another participant also told of family support, especially a wife, for the recovery of patients, “His wife… doesn’t see him as the one who gets sick. It’s really good” (P6).

Theme 2: Recovery as an unfamiliar term with various meanings

Most of the participants in this study had never heard of the term recovery, but all participants could interpret it based on their caring experience. Thus, the meaning of recovery varies greatly. The participants expressed this: “I’ve never heard of recovery” (P2). Other participants also said the same thing, “Never heard of recovery” (P3), “I’ve never heard of it before” (P5), “I haven’t” (P6). Another participant revealed that he had heard the term recovery in general. However, it is not specific to mental health. He said, “I’ve ever heard of recovery in general health, but for mental health, not yet” (P8).

Furthermore, participants interpreted recovery by saying, “Recovery means that the mind-body is back to normal like people without mental disorders” (P8). Meanwhile, other participants who had never heard of recovery also stated, “Recovered means a person who is healthy, who has recovered from mental, physical, and mental disorders” (P2). Another participant said, “Recovery is for patients, who initially could not interact with nurses, finally were able to interact” (P7).

However, another participant said something different revealed that it would not happen for a complete recovery like ordinary people. He stated, “Recovery means all things related to schizophrenic disorder are no longer there or finished. The meaning of completion means you will recover like a normal person; it’s not possible” (P1). It is also more surprising from the statement of other participants who did not explain the meaning of recovery but revealed that recovery from schizophrenia was difficult. He said, “Recovery from mental disorders, such as schizophrenia, seem difficult” (P5).

Theme 3: Medication as the primary action but also the main problem

All participants said that medication is vital for the recovery of schizophrenia and the main action of mental health services. However, the available drugs are very limited or not available at the Puskesmas. One participant said, “I think the main action is just medicine” (P5). Another participant also said, “For people with mental disorders, the emphasis should be on medicine. Alternative approaches are difficult. I have tried, but it can’t work; it just gets worse” (P1).

Participants expressed the importance of medication for patients because the patient gets better and does not relapse by taking medication. This was said by one participant, “If they have taken medicine, they can work. Communication is also good” (P3). This is supported by another participant’s statement, “After taking medicine, the patient wants to take a shower himself without being asked” (P6).

The importance of drugs for patients is not supported by the supply of drugs at the Puskesmas. Some participants said, “Our obstacle from the Puskesmas is that the available medicines for people with mental health disorders” (P7). The other participant also complained and despaired about the very limited drug, “Hopefully the Almighty will help them so that they can recover. But, unfortunately, we do not know what else to do; medicine is limited. So, patients’ recovery is also difficult” (P4).

Chlorpromazine (CPZ) is a drug that is still available at the Puskesmas. Participants expressed this, “Medicines are limited, the drugs are from Ambon (Capital city of Maluku). There are only CPZ here” (P3). Another participant continued by revealing, “The medicine provided at the Puskesmas is only CPZ. But if we need more than that, we have to refer to a specialist at RSKD Ambon (Ambon Hospital)” (P8). The limitations of drugs made some participants look for solutions by making referral letters for taking medications at a mental hospital in Ambon. One of the participants said, “We have to go get the medicine in Ambon” (P4).

Additionally, even though the family is given a referral for free medication in Ambon, several obstacles are raised, such as financial constraints for traveling costs. For example, to reach the farthest health center, they have to travel ±5-6 hours by land, then by sea for ±8-9 hours later to a mental hospital. Even if there are families in Ambon who can pick them up, they have to pay for the care. One participant expressed, “To recover, it depends on economic factors. Because to take medicine in Ambon, it costs money because it is so far. Moreover, the patient’s family is also having difficulty” (P5).

Theme 4: Being recovered if referred to a mental hospital

Participants said that patients could recover if they were referred to a mental hospital. One of them said, “If they were referred, they could be recovered” (P3). Another participant expressed the same thing, “They can be cured but must be referred. For example, one of them is to get ta treatment at Nania (a mental hospital in Ambon). The point is that they must be referred because there are doctors and nurses; they have everything” (P2).

Other participants also support that referral will make the patient recover because of the supportive treatment and facilities compared to the Puskesmas. One participant stated, “If referred, the patient can get good treatment at the hospital. But if he stays here, it will be difficult for him to recover. However, if they are treated there (at RSKD Ambon hospital) for one month, they will be able to recover in two months” (P4).

Theme 5: Ineffective mental health programs

There was a lack of attention from the Puskesmas and the Health Office on mental health programs. The participant who has been in charge of mental health programs for 14 years revealed, “There is not enough attention to mental health programs. The leaders until the staff think that mental problems are not important” (P1). Other participants also expressed criticism, “I see that the budget for drugs is limited. The department also often rolls out, so this mental program cannot be developed” (P8).

One of the participants revealed that the activities carried out every year are assisting programs, tracking new cases, and socialization. However, one activity is always left out for the following year to replace other activities due to budget constraints. The participant said, “I do activities with limited funds. For example, for this year, I only do the mentoring and tracking. So, every year, one planned activity cannot be done” (P4). In addition, the very limited circumstances make the person in charge of the mental program rarely visit the patient because of the long distance. One participant said, “The distance between the patients and us is very far. So, we visit patients once a year or two. Sometimes, we do visits after four months” (P2).

Discussion

This study aimed to explore the perspectives of nurses regarding the recovery from schizophrenia. Five themes were generated, and each theme is discussed below.

Treat a patient like a brother

This theme indicates that nurses show sincerity and willingness in caring for patients with schizophrenia and sacrifice to serve patients with their hearts. This finding is consistent with Majomi et al. (2003) that nurses sacrifice to be professional despite many personal problems at home. However, nurses must do their best for patient recovery (Majomi et al., 2003). Moreover, this finding is also consistent with Buckland et al. (2013) revealed that nurses must be able to bring happiness to patients to improve their quality of life. Kaewprom et al. (2011) also found that nurses are key people in facilitating recovery to patients in the community. Another finding by Coffey and Hewitt (2008) revealed that in a situation where the patient is struggling to recover, the nurse supported the patient by being a good listener when the patient needed it. It is also in line with Suryani (2013) that nurses become facilitators for all actions, needs, feelings, abilities, and weaknesses of patients. However, although nurses are recognized as critical persons (Kaewprom et al., 2011), able to bring happiness (Buckland et al., 2013), good listeners (Coffey & Hewitt, 2008), people who make sacrifices (Majomi et al., 2003), and facilitators (Suryani, 2013). However, no studies have revealed that nurses are brothers to patients, and this theme is quite important as a new insight in this study.

In addition, the findings of this study also show support and concern from the family or community for the recovery of the patients. The results of this study are consistent with previous qualitative research by Karanci et al. (2017), Riley-McHugh et al. (2016), Shepherd et al. (2012), and Windell and Norman (2013), which revealed that support from family and community is essential for the recovery of patients with mental disorders. For example, the expression of one of the participants in the study of Shepherd et al. (2012) said, “the people here, we talk, we laugh, we joke, and they’re always there for me. If I feel bad, they’re always there to help me go through it together. And I think I feel better about myself now than I did when I was a kid.” Likewise, Riley-McHugh et al. (2016) said that support from the family could be a coping mechanism for patient recovery. The same thing was also expressed by Karanci et al. (2017) that there are three kinds of family supports to patients in facilitating patient recovery, including instrumental support (basic needs, material support, information support, and daily tasks), emotional support, and socialization support. Besides, most of the quantitative research has also explored family and community support for patients. For example, Norman et al. (2012) showed that social support was positively correlated with treatment and reduced stigma. Similarly, McCorkle et al. (2008) showed that, with assistance, family support for clients increased from 13% to 23% and improved symptoms and patient well-being (McCorkle et al., 2008).

The support of nurses, families, and communities to other people, including patients, for the Moluccans, is called Hidop orang basudara [we are brothers]. This culture is very strong, an inseparable part, a bond of social life, and inherent in the people of Maluku. Therefore, nurses consider patients as siblings or brothers and sisters. This finding is in line with the ethnographic study by Acim et al. (2019) that Hidop orang basudara [we are brothers] as a way of life by emphasizing the values ​​of protecting each other (baku kalesang), making peace with each other (baku bae), and caring for or loving each other (baku sayang). However, the support of nurses, families, and communities becomes a supportive environment in the patient recovery process. Adults also understand patients by not mocking, although children often laugh at the patient’s quirky behavior and make the patient angry.

Recovery as an unfamiliar term with various meanings

Most of the participants in this study had never heard of the recovery of people with mental disorders. However, even though the participants were still unfamiliar with recovery, it was defined as regaining health as before the disorder or returning to normal, not being dependent on drugs, having no symptoms, and being able to interact with other people. This finding is in line with Kaewprom et al. (2011) found two states of recovery in patients with schizophrenia, namely the controlled state and the return state. The controlled state is related to stabilizing the symptoms experienced, while the return means that the patient’s function returns to normal before experiencing the disorder.

The findings in this study are also in line with Suryani (2014) stated that participants’ understanding of recovery is suitable for conditions of physical illness such as fractures, diarrhea, or other diseases. The same thing was expressed by Onken et al. (2007) that recovery is not the same as treatment which requires the disappearance of symptoms from the disease. So, the recovery of schizophrenia is the patients can control the symptoms and control their life as a whole. This is in line with Shea (2010) revealed that recovery means that the patient is able to have control over his life even though there are still symptoms, is able to develop himself in a positive direction, and knows about the disease he is experiencing and his goals in life.

Additionally, the findings of this study also reveal that recovery is difficult in patients with schizophrenia. This means that participants see recovery as an unrealistic expectation. This finding is in line with Suryani (2013) that nurses can damage the patient’s recovery process because their understanding and attitudes are not in line with recovery. This is supported by Shean (2009) that the pessimistic attitude of health workers should have been replaced with a recovery perspective. Perspectives to build patient expectations lead them to have a productive and meaningful life (Shean, 2009). One of the participants in the qualitative research of Barut et al. (2016) revealed the importance of a sense of belonging, hope, and responsibility. She said, my nurses, they let me know what to do, and if I don’t do it, I see it.

van Langen et al. (2016) also revealed that nurses must recognize and prevent patient relapse, empower them and their families, and be good friends for patients to openly share experiences related to their illness. Thus, the findings in this study provide essential information about the erroneous perspective on recovery of the nurses in charge of the mental program in Buru District, Maluku, Indonesia.

Medication as the primary action but also the main problem

This theme indicated that medication is the main action in the recovery of people with a mental health condition. This is because the drugs can only restore the patients as perceived by the participants. This study also found that the standard supply of medicines in the Puskesmas is Chlorpromazine (CPZ). This is consistent with Gaebel et al. (2020), which recommends that CPZ doses of 300-600 mg or below 600 mg are effective for long-term antipsychotic treatment. Adams et al. (2014) also found that CPZ reduced relapse and improved the mental health functioning of patients. However, this review also revealed that CPZ has side effects, such as drowsiness, tremors, weight gain, decreased blood pressure, and dizziness. Similarly, Samara et al. (2014) found that CPZ only had an advantage over four antipsychotics in treating patients with schizophrenia. Different things were expressed regarding the effectiveness of CPZ by Meng et al. (2018), who revealed that CPZ is effective for improving sleep quality in patients with schizophrenia, reducing positive, negative, and general symptoms of schizophrenia and anxiety.

Apart from being the main action, medication is also a significant obstacle for nurses caring for patients. There are limited drugs for medication at the Puskesmas, so the family had to take medication at the mental hospital. Unfortunately, this has also become another issue for the family, such as the cost of traveling, long distances by traveling 10-12 hours, and the wave season sometimes becomes a problem.

However, the main issue is about the participants’ perspectives who consider only the medication was the main recovery action for the patients. The participants in this study ignored other aspects of recovery, such as empowering patients and families, developing patient expectations for recovery (not only mental but also physical services), assessing the patient’s strengths and being responsible for what is done, and developing respect for society to the patients (National Academies of Sciences Engineering Medicine, 2016).

Being recovered if referred to a mental hospital

This theme indicated that referring the patients to the hospital will make them recovered because they get better treatment with adequate facilities, professional health workers, availability of medicines, and patient needs compared to limited facilities at the Puskesmas. This finding is in line with Shen and Snowden (2014) revealed that developing countries are difficult to build deinstitutionali-zation due to a shortage of mental health personnel, low physical and mental health services, and limited medicines for mental disorders in primary care. The de-institutionalization policy is a global policy that has also been implemented in Indonesia (Idaiani, 2009). This policy is stated in Law Number 18 of 2014 article 34 that mental health services are carried out in an integrated manner in public health services, one of which is at the Puskesmas (Ministry of Law and Human Rights, 2014).

Another study by Samele et al. (2013) also revealed that the treatment of patients with mental health disorders in the community is more effective than the treatment in a hospital. This is because community-based services reduce the number of patient relapses. In addition, Slade (2010) also revealed that patients with schizophrenia could live in the community if health workers carry out close monitoring with obedient treatment from patients.

The nurses’ perspectives in our study are described by Suryani (2013) as a condition in the 1960s, where the orientation of mental health services was centered in a mental hospital although a policy for mental health services in Indonesia exists in the community/health center. So, these findings can be an input for evaluating mental health services in Maluku, Indonesia.

Ineffective mental health programs

The majority of participants in this study thought that mental health programs did not work well compared to other health programs. This is reflected in the limited budget for activities, the unrealized demand for drugs for patients, and frequent changes in the person in charge of the mental program. The findings of this study are in line with the 2015-2019 action plan of the Directorate of Prevention and Control of Mental Health Problems and Drugs and the Regulation of the Minister of Health Number 87 of 2019 concerning Guidelines for the Use of Deconcentration Funds of the Ministry of Health for the Fiscal Year 2020 (Ministry of Health of Indonesia, 2018, 2019b), which shows that mental health programs have not become a priority program with weak supervision of mental health services in the regions, and Puskesmas has not provided mental health services according to standard. In addition, there are limited psychotropic drugs at the Puskesmas, unequal mental health resources, and the budget for mental health included in six disease prevention and control programs with a total 2020 budget of 206 billion. Besides, another report by Ito et al. (2012) revealed that low-income countries, including Indonesia, only budgeted 1% for the mental health of the total health budget. This is supported by Idaiani (2009) that existing mental health policies in Indonesia are not supported by adequate funding systems.

In the findings of this study, participants tried to find solutions related to drugs accessibility and affordability by handing them over to the family. However, this activity only lasted a few months and has stopped. This is related to the limited financial condition of the patient’s family. Another option by the family to entrust the referral for taking medication also requires high cost for traveling with cars and ferry. In addition, there must be someone in Ambon, the capital city, who is willing to pick up medicine at a mental hospital to be sent back.

Implication for Nursing Practice and Healthcare Policy

Globally, this study provides a new insight that every human being, including nurses, should treat other humans (patients) as brothers. Therefore, hidop orang basudara [we are brothers] is expected to be one motto for nursing care in Indonesia and beyond. In addition, this study has filled the literature gap as the evidence was only developed in the Western part of Indonesia (Suryani, 2013, 2014, 2018; Agustina et al., 2019). On the other hand, the picture of mental health services in Maluku, the Eastern island, is still lagging in terms of recovery orientation, which focuses only on medication and referring patients to mental hospitals. So, these findings can be input for nurse managers and mental health policymakers in districts and provinces to optimize recovery-oriented mental health services in Indonesia and other developing countries.

Nationally, this finding represents a general picture in the Eastern island of Indonesia regarding mental health services that have not become a priority program for the government. However, Puskesmas is the key to the success of mental health services. The reality in the field is that the Puskesmas is only an agent to refer patients to mental hospitals. This finding is essential for the central and local governments to pay attention to mental health programs and budgeting to develop mental health services, including patient recovery in Puskesmas.

Limitations of the Study and Recommendations for Future Research

This study might not represent the whole context of Eastern islands in Indonesia. Therefore, future studies with all regions should be conducted. Besides, an explorative study from the perspectives of both survivors and caregivers is needed. Culture-related research and model development, such as 3C (Cure, Care, Core (Continuing recovery)) in mental health recovery warrant investigation.

Conclusion

The findings of this study provide the context of nurses’ understanding of the recovery process of patients with schizophrenia in the Easter island of Indonesia. The results offered new knowledge on how nurses act to the patients with the motto “we are brothers” that could inspire others in caring practice. However, this study also identified the issues that should be solved by nurse managers and policymakers in making the same views of nurses regarding the recovery process, which is not only from medical treatment and referral to hospitals but also from nursing care and family or community support. The policymakers are also suggested to be more focused on the mental health program in the Puskesmas considering the inequality of development regarding accessibility and affordability of healthcare services, infrastructures, availability of drugs between the remote areas and the city.

Declaration of Conflicting Interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ Contributions

FAT contributed to the conceptual, design, data collection, data analysis, data interpretation, and manuscript drafting. SS, TS, and SRM contributed to study formulation and intellectual content and critically wrote and revised the article. All authors agreed with the final version of the paper. Each author in this study met the authorship criteria based on the International Committee of Medical Journal Editors.

Authors’ Biographies

Fandro Armando Tasijawa, S.Kep., Ners., M.Kep is a Lecturer at the Faculty of Health, Universitas Kristen Indonesia Maluku, Indonesia.

Suryani, SKp., MHSc., PhD is a Professor at the Department of Mental Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia.

Titin Sutini, S.Kep., Ners., M.Kep is a Lecturer at the Department of Mental Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia.

Sinthia Rosanti Maelissa, S.Kep., Ners., M.Kep is a Lecturer at the Faculty of Health, Universitas Kristen Indonesia Maluku, Indonesia.

Data Availability Statement

All data generated or analyzed during this study are included in this published article (and its supplementary information files).