Abstract
Introduction
Therapeutic commitment of general nurses influences their provision of mental health care to clients. It is the general nurses' predisposition for working therapeutically with clients who have mental health problems (MHPs). In Malawi, general nurses are the majority of health care professionals who care for people living with HIV/AIDS (PLWHA) and they are expected to deal with the mental health problems of these patients. The provision of mental health care to PLWHA is vital because apart from the physical illnesses associated with the virus, these people are also affected by mental health problems. However, most general nurses, feel neither confident nor competent when dealing with the mental health problems of their clients in Malawi. This may negatively influence their therapeutic commitment in dealing with mental health problems of PLWHA. However, therapeutic commitment of general nurses in providing mental health care to PLWHA in Malawi remains unknown.
Materials and Methods
The study used a quantitative descriptive survey design. a convenient sample comprising of 136 general nurses was used and data was collected using Mental Health Problems Perception Questionnaire. Permission to use the tool in this study was granted by Prof. Lauder. Ethical approval to conduct the study was granted by Ethics Committees at University of KwaZulu Natal and University of Malawi. Data were analysed using Statistical Package for Social Sciences version 15.0.
Results
The study findings revealed that there is a linear relationship between general nurses' levels of knowledge and skills and their therapeutic commitment (r=.40, n=136, p<.05) to provide mental health care of PLWHA.
Conclusion
This study suggests general nurses' levels of therapeutic commitment in dealing with MHPs of PLWHA vary and their levels of knowledge and skill to deal with MHPs influence their willingness to provide mental health care to PLWHA.
Introduction and background
Therapeutic commitment of general nurses influences their provision of mental health care to clients. It is defined as a predisposition for working therapeutically with clients who have mental health problems (MHPs) and it is a prerequisite for effective therapeutic intervention1. However, most health workers in Malawi, including general nurses, feel neither confident nor competent when dealing with the MHPs of their clients2. This may negatively influence the general nurses therapeutic commitment in dealing with MHPs of people living with HIV/AIDS (PLWHA). The provision of mental health care to PLWHA is important because apart from the physical illnesses associated with the virus, these people are also affected by MHPs3. A study that was conducted in Malawi by Mwale4 found a prevalence rate of 14.4% of MHPs amongst PLWHA who attended Antiretroviral Therapy (ART) clinics in Mzuzu. MHPs are disturbing human emotional and psychological experiences5 such as depression and psychosis. Hence it is important that health care providers who care for PLWHA are skilled and committed to deal with MHPs of these people. This is in line with the recommendations of the World Health Organisation which promotes the integration of mental health services with general health services, where non-mental health specialists should take part in the provision of mental health care6.
It is evident that HIV/AIDS intervention programmes must include mental health care if they are going to be successful because among other things, MHPs significantly impede antiretroviral therapy adherence3. As such health professionals dealing directly with PLWHA must effectively manage the MHPs affecting PLWHA in order for them to achieve successful outcomes. However, there is very little reference to mental health care in the HIV/AIDS programmes that are being implemented across the country in Malawi7 although the National HIV/AIDS Policy does recognise that PLWHA are affected by MHPs8.
The majority of health care professionals who care for PLWHA in Malawi are general nurses and they are expected to deal with the MHPs of these patients. There are 2.5 mental health nurses per 100 000 of the population9 and only one psychiatrist is employed by the Ministry of Health to care for more than thirteen million people. Of the 13 077 160 people in Malawi10, there are almost 900 000 adults (14%), between the ages of 15 and 49, living with HIV/AIDS in Malawi11.
The provision of mental health care to PLWHA helps care provider to render holistic care to these people in view of the fact that PLWHA are also affected by MHPs12–20. As such, the objective of this study was to determine the general nurses' commitment to providing care to PLWHA with mental health problems. Literature suggest that the effectiveness of general nurses' interventions depend on their level of therapeutic commitment16. Health workers who have greater therapeutic commitment in working with MHPs, are more likely to successfully manage clients with MHPs17. Hence, it would only be logical to propose that general nurses may be more likely to deal successfully with MHPs of PLWHA if they feel that they have high levels of therapeutic commitment. This may provide an opportunity for improving the health of PLWHA in particular, and expanding mental health services in general health services3. Nevertheless, little is known about general nurses' therapeutic commitment in dealing with MHPs of PLWHA because the topic has never been researched in Malawi. Therefore, a study was conducted to explore general nurses' therapeutic commitment in dealing with MHPs of PLWHA in Malawi.
Methods and materials
Design
A quantitative descriptive survey design was used for this study to help describe general nurses' therapeutic commitment in dealing with MHPs of PLWHA.
Setting
The study was conducted at Queen Elizabeth Central Hospital (QECH) in Blantyre district, Malawi
Sample
The study used a convenience sample comprising of 136 general nurses working at QECH. General nurses with less than 2 years post-graduation working experience or without exposure to PLWHA who have MHPs were excluded from the study.
Materials
The study used a questionnaire adapted from the Mental Health Problems Perception Questionnaire (MHPPQ)18 to collect data. In this study, the questions focused on general nurse's therapeutic commitment, knowledge and skills in providing mental health care to PLWHA. The adapted MHPPQ was tested prior to data collection in Malawi. The computed Cronbach's alpha for the therapeutic commitment scale of MHPPQ was α=0.74 and that for knowledge and skills scale was α=0.73. This indicated satisfactory internal reliability of the instrument.
Procedure
Permission to use the Mental Health Problems Perception Questionnaire (MHPPQ) in this study was granted by Prof. Lauder. Ethical approval was granted by Human Research and Ethics Committee at University of KwaZulu Natal and College of Medicine Research and Ethics Committee at University of Malawi while institutional clearances were granted by Blantyre District Health Office and Director of QECH in Blantyre district. General nurses who gave written consent to participate in the study were given a self-administered questionnaire which they completed at their convenience. 136 completed questionnaires were personally collected from the participants by the researcher at an agreed time.
Data analysis
Data were analysed using Statistical Package for Social Sciences (SPSS) version 15.0. Descriptive statistics were used to analyse data. Spearman's rho test was used to test correlation between variables.
Study findings
There were 84.6% (n=115) female and 15.4% (n=21) male general nurses who participated in this study of which 28.6% (n=39) were Registered Nurses and 71.4% (n=97) were Nurse Midwife Technicians. These participants were drawn from Maternity ward (25.7%, n=35), Paediatric ward (19.1%, n=26), two Surgical wards (17.6%, n=24), two Medical wards (21.3%, n=29) and other departments (16.3%, n=22). Some of the participants (22.8%, n=31) did not receive any mental health lectures as part of their initial training but they work in medical wards where they frequently come in contact with PLWHA since the HIV prevalence rate is very high in Malawi .
The findings of this study revealed that general nurses' therapeutic commitment in dealing with MHPs of PLWHA vary (Table 1). Almost half of the participants (45.6%, n=19) did not want to work with PLWHA who have MHPs. Nevertheless, 80.1% (n=109) of the participants agreed with the statement that “I feel that I have something to offer PLWHA who have mental health problems.” This may mean that some general nurses had positive self perceptions about their provision of mental health care to PLWHA while others did not. It was intriguing to learn from the findings of this study that some participants had passion for caring PLWHA who have MHPs (Table 1).
Table 1.
Responses to therapeutic commitment scale items.
| Statement | Disagree | Agree |
| n(%) | n(%) | |
| I am interested in the nature of mental health problems of PLWHA and the treatment of them |
31(22.8) | 105(77.2) |
| I feel I am able to work with PLWHA who have mental health problems as effectively as other patients who do not have mental health problems |
31(22.8) | 105(72.8) |
| I want to work with PLWHA who have mental health problems | 62(45.6) | 74(54.4) |
| I feel that there is nothing I can do to help PLWHA who have mental health problems | 126(92.6) | 10(7.4) |
| I feel that I have something to offer PLWHA who have mental health problems | 27(19.9) | 109(80.1) |
| I feel that I have a number of good qualities for working with PLWHA who have mental health problems |
42(30.9) | 94(69.1) |
| Caring for PLWHA who have mental health problems is an important part of nurse role | 9(6.6) | 127(93.4) |
| In general, one can get satisfaction from working with PLWHA who have mental health problems |
59(43.4) | 77(56.6) |
| I often feel uncomfortable when working with PLWHA who have mental health problems |
114(83.8) | 22(16.2) |
| In general, I feel that I can understand PLWHA who have mental health problems | 42(30.9) | 94(69.1) |
| On the whole, I am satisfied with the way I work with PLWHA who have mental health problems |
91(66.9) | 45(33.1) |
| In general I find working with PLWHA who have mental health problems difficult | 95(69.9) | 41(30.1) |
With regard to knowledge and skills, the results indicated that there were variations in participants' levels of knowledge and skills in caring for PLWHA who have MHPs (Table 2). Some participants (56.6%, n=77) felt that they had the necessary knowledge and skills to care for PLWHA who have MHP, while others, 43.4% (n=59), felt that they did not. More than half of the participants, (57.4%, n=78) indicated that they perceived themselves as not having enough knowledge about factors that put PLWHA at risk of MHPs. The results of this study also revealed that majority of the participants (59.6%, n=81) do not know how to treat PLWHA who have long term (or chronic) mental health problems. It is clear from these study findings that some nurses had higher levels of knowledge and skills than others.
Table 2.
Responses to knowledge and skills scale items.
| Statement | Disagree | Agree |
| n(%) | n(%) | |
| I feel that I know enough about the factors that put PLWHA at risk of mental health problems | 78(57.4) | 58(42.6) |
| I feel that I know how to treat PLWHA who have long term (or chronic) mental health problems | 81(59.6) | 55(40.4) |
| I feel that I can appropriately advise my patients who are infected with HIV/AIDS about mental health problems |
42(30.1) | 95(69.9) |
| I feel I have clear idea of my responsibilities in helping PLWHA who have mental health problems | 52(38.2) | 84(61.8) |
| I feel I have the right to ask my patients who are infected with HIV AIDS about their mental health status |
39(28.7) | 97(71.3) |
| I feel that my patients who are infected with HIV/AIDS believe I have a right to ask them questions about their mental health problems |
68(50.0) | 68(50.0) |
| I feel that I have the right to ask PLWHA for any information that is relevant to their mental health problems |
30(22.1) | 106(77.9) |
| I have the skills to work with PLWHA who have mental health problems | 77(56.6) | 59(43.4) |
| I feel I have the skills to assess and identify PLWHA who have mental health problems | 61(44.9) | 75(55.1) |
| I often have the difficulty knowing how to communicate with PLWHA who have mental health problems |
104(76.5) | 32(23.5) |
| I feel I know how to treat PLWHA who present in a crisis with signs of mental health problems | 81(59.6) | 55(40.4) |
| I often have difficulty knowing how to assess PLWHA who have mental health problems | 101(74.3) | 35(25.7) |
Furthermore, the findings of this study revealed that there were no significant differences in the levels of therapeutic commitment, knowledge and skills in relation to age, gender, work experience, workplace or whether mental health lectures had been received during training. This was evident by the calculated p values of the Kruskal-Wallis Test and the Mann-Whitney U Test, which were >.05. On the other hand, it was clear from the calculated Spearman's rho correlation coefficients that a medium positive linear correlation exists between therapeutic commitment and knowledge and skills, r=.40, n=136, p<.05, with higher levels of knowledge and skills being associated with higher levels of therapeutic commitment as indicated by the scatter plot (Figure 1).
Figure 1.
A scatter plot showing the relationship between general nurses' levels of knowledge and skills and their therapeutic commitment
Discussion
It is clear from the study findings that therapeutic commitment in dealing with MHPs of PLWHA differs among general nurses. In this study some nurses (54.4%, n=74) felt that they were willing to care for PLWHA with MHPs while others were not. These findings are consistent with previous studies that were conducted in other parts of the world19–22. Some contributors to nursing literature assert that nurses' positive feelings towards people who have MHPs increase their desire to provide mental health care to these people in general settings while negative feelings lead to discrimination which reduces the ability of the nurse to provide relevant mental health care21. Thus, the findings of this study suggest that general nurses who have positive feelings about MHPs may be willing to provide mental health care to PLWHA. This is supported by a body of literature which state that nurses who have positive self perceptions towards MHPs acknowledge mental health care as part of their nursing role and are willing to help22. In this study, 93%, (n=127) agreed with the statement that “Caring for PLWHA who have MHP is an important part of a nurse's role”. However, the general nurses' positive or negative self perceptions towards MHPs are influenced by their perceived levels of knowledge, skills and access to relevant support23. It follows that nurses who perceive themselves as having adequate knowledge, skills and support may have positive self perceptions towards MHPs and may usually be willing to care for PLWHA who have MHPs and vice versa. This is supported by the Theory of Therapeutic commitment which proposes that levels of knowledge and skills have a direct influence on the therapeutic commitment of nurses1. However, the issues of nurses' knowledge and skills are not the main focus of this paper.
In this study, it was revealed that there is a relationship between general nurses' levels of knowledge and skills and their therapeutic commitment (r=.40, n=136, p<.05). The increase in the levels of knowledge and skills was associated with an increase in levels of therapeutic commitment. A similar study in Australia found that nurses with specialist clinical experience in mental health had higher levels of therapeutic commitment in providing mental health care in general hospitals than those without specialist clinical experience23. Thus, it can be inferred that improving general nurses' levels of knowledge and skills may increase their therapeutic commitment (Figure 1). Literature shows that improving basic nursing education regarding mental health from entry to practice, and providing supplementary clinical mental health education to nurses who are practicing, may improve their competencies and confidence in dealing with MHPs24. This may imply that the more general nurses are knowledgeable and skilled in dealing with MHPs the more willing they become to deal with MHPs of PLWHA. It was motivating to find out that some participants in this study were interested in providing mental health care to PLWHA. Their willingness to deal with MHPs may have provided them an opportunity of building therapeutic relationships with PLWHA, which is fundamental to the provision of holistic care.
Strengths and limitations of the study
The strength of this study is that a reliable instrument was used to collect data18 and the findings are similar to those that were found in South Africa and Australia20,23. However, the limitation of this study is that it was not able to uncover the reasons which influence general nurses commitment to care for PLWHA with mental health problems. In addition, the findings of this study may not be generalized to other settings across the country because data was collected from one district only.
Recommendations
Overall, the study reveals a remarkable opportunity for improving the mental health care of PLWHA in general settings in Blantyre, Malawi. Unfortunately, general nurses usually lack willingness to address MHPs of PLWHA. Nurses who feel that they lack knowledge, skills and support may be unwilling to engage themselves with MHPs of PLWHA for fear of uncovering problems which they may find themselves unable to deal with. Therefore, it is essential that general nurses have access support and to ongoing training and in-service education on mental health issues which may give them an opportunity of improving their knowledge and skills and consequently their therapeutic commitment in dealing with MHPs of PLWHA21.
Conclusion
This study suggests general nurses' levels of therapeutic commitment in dealing with MHPs of PLWHA vary and their levels of knowledge and skill to deal with MHPs influence their willingness to provide mental health care to PLWHA.
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