Competence of general practice nurses caring for patients with mental health problems in the somatic departments.

OBJECTIVE. To investigate competence of general practice nurses caring for patients with mental health problems in the somatic departments. MATERIAL AND METHODS. A quantitive study on competence of general practice nurses using an anonymous questionnaire was carried out in Klaipeda secondary health care institution in January-February of 2007. The respondents (128 general practice nurses) were selected from seven departments, in which psychiatric consultation was more frequently recommended. In the working places of nurses, 140 questionnaires were distributed; 135 questionnaires were completed (response rate was 96.4%), among them 7 questionnaires were acknowledged as not valid. RESULTS. About 45.0% of general practice nurses had knowledge how to care for the patients with mental health problems, from 1.6 to 21.9% did not have knowledge, and the rest reported having only moderate knowledge (28.1-64.1%). These findings provided a statistically significant link between the duration of employment and education (r from 0.292 to 0.76; P from <0.05 to <0.01). However, only 30.5% of respondents were able to manage conflicts. Most common undesirable events (60.3%) were runaway from inpatient clinic care, injury followed by runaway (29.4%), and suicide (10.3%). From 18.8% to 28.9% of respondents believed that undesirable events were influenced by an unsuitable environment of the department, the shortage of time and personnel, difficulty in getting a psychiatrist's consultation. Only 3.1% of respondents thought that these undesirable events might be affected by the lack of competence of personnel. Most of the nurses (form 75.0% to 84.4%) had a positive attitude toward the patients; however, the nursing principles were recognized only by (6.3% to 24.2%) of respondents. CONCLUSIONS. Competence of the nurses caring for the patients with mental health problems is not at the level required. This may be associated with insufficient professional skills, conflict situations with the patients, and the lack of acknowledgment of the principles of nursing.


SLAUGOS MOKSLAS Introduction
We are living at the time of the development of scientific knowledge and technology when cities, their industry and transport are growing rapidly. Due to the pace of modern life, with an increase of the enormous flow of information, human mental and emotional tense are also growing. We are exposed to a busy life everywhere and all the time that is why we feel tense and, thus, are not able to relax and have a rest. We are in nervous disposition, experiencing difficulties in communication with others, and in general, we are not able to take joy any more (1). This affects the human body, damages the nervous/mental system, and leads to neurosis, alcoholism, drug use, depression, higher rate of birth of children with physical and mental inferiority. According to the data of the World Health Organization, 30.0% to 50.0% of all patients in hospitals of developed countries are suffering from various mental disorders (2). This fact worries physicians, scientists, state officers, society because good mental health is a key factor in human existence and society welfare. Current research shows that a group of mental disorders is in the leading position contributing to the burden of diseases. The population of the East Europe has been struck down by early deaths, which are related not to common body afflictions but to emotions, psyche, and behavior (3). Psychological factors induce somatic disease, and somatic factors may be a cause of mental disorders. The findings of scientific studies showed that sufferers from somatic diseases and patients with mental disorders more frequently become handicapped; thus, they need health care services. This group of patients is in demand of prompt and qualified help (4). A dramatic change can be observed by people who surround a person, while a slight change may be detected only by physicians. If mental disorders are not recognized in time, harm may be caused not only to a person but also to a society as well (5). To help a patient it is necessary to know the features of mental disorders, to understand and be able to evaluate them. These disorders are detected by carrying out special psychological tests, by talking to the patients, observing their behavior; thus, the role of a nurse is very important. The key role is assigned to these specialists because they have more relationships with the patients (6). Changes taking place in social, economic, and cultural life of Lithuania influence the demand of nurse to obtain new knowledge, skills, and abilities. The term competence describes the persons that have appropriate professional status and characterizes their level of knowledge, abilities, perception that correspond the requirement of performed tasks or solution of problems (7). However, often general practice nurses lack skills and understanding of how to meet the complicated demands of the patients with mental health problems. Most of these patients suffer enormously, and this suffering is amplified by the presence in hospital. Nurses frequently are disappointed with possibility to help the patient, and it seems that most of them do not believe in the importance of their personal behavior with a patient. The main attention is paid to the physiological aspects while mental health problems are often ignored; thus, most of the patients are solitary in their sufferings. Therefore, it is very important to train nurses with their active participation on a continuing basis because good patient-oriented health care is only possible when the professional demands of employees are satisfied (8,9).
The aim of this study was to examine competence of general practice nurses caring for the patients with mental health problems in the somatic departments.

Methods
The study on competence of general practice nurses was conducted in Klaipėda secondary care institution during January and February of 2007. A total of 128 general practice nurses from the following departments were enrolled into the study: gastroenterology, cardiology, internal diseases and diagnostics, surgery, palliative treatment and nursing, resuscitation and intensive therapy, rehabilitation (after sustaining stroke). These patients more commonly need a psychiatrist's consultation. The hospital departments, where the study took place, were selected using the 2006 registry of on-call and reception consultations. The study comprised only nurses working in the somatic departments and having at least one year of experience. The age of respondents was from 20 to 55 years. The mean age was 39.96 (SD, 0.33) years. Less than three-fourths (72.6%) of nurses had been working for up to 20 years; employment of 20 years and more was reported by 27.4% of respondents. The mean duration of employment was 14.28 (SD, 9.83) years. Less than one-third (29.0%) of participants of the study reported to have special secondary, 29.0% had university higher education, and 42.0% of respondents had non-university higher education. To carry out a study on competence of general practice nurses, a questionnaire was developed based on the legal regulations of rights, duties, competence, and responsibility of general practice nurses, the Law of the Republic of Lithuania on the rights of Patients and Compensation for the Damage to their Health (10), the European Charter of Patients' Rights and the European Patients Rights (11). An anonymous questionnaire consisted of 29 questions, which were related to the following issues: demographic data (3 questions), knowledge of nurses (9 questions), skills (9 questions), attitude toward patients with mental health problems (8 questions). All respondents before the survey were informed about the aim of the study, and anonymity and confidentiality were guaranteed. All respondents had an opportunity to cancel their participation at any stage of the study. Permission to perform this study was given by the director of the Hospital. An anonymous questionnaire was performed in written. A total of 140 questionnaires were distributed in the working places of nurses, 135 questionnaires were answered (response rate was 96.4%), and 7 questionnaires were recognized as invalid.
Statistical data analysis was performed using the software package SPSS 13.0 for Windows and Microsoft Office Excel 2003. Correlation analysis of variables was carried out by applying rank correlation coefficient of Spearman. Analysis of hypotheses of independency link strength between variables was evaluated applying contingency coefficient and Kendall's coefficient. Difference between data was considered significant when P was <0.05 (confidence level, 95%).

Results
The answers of respondents are presented in Tables 1-3. Table 1 shows that from 32.8% to 82.8% of general practice nurses (according to the questions presented in the questionnaire) had knowledge of how to care for the patients with mental health problems, from 1.6% to 21.9% of nurses did not have knowledge, and from 28.1% to 64.1% reported moderate knowledge. The results of assessment of knowledge show that 82.8% of respondents knew how to advice the patients with mental health problems and seeking for help (Table 1). Correlation analysis showed that there is a statistically significant link between knowledge of nurses and their employment duration. Duration of employment correlates with knowledge of the principles of drug action (neuroleptics, tranquillizers, antidepressants) (r=0.76, P<0.05); ability of nurses to detect possible threats to a patient's or other persons' health and life (r=0.292; P<0.01); the methods used to resolve conflicts caused by the patients with mental problems (r=0.245; P<0.01). Education was also related to knowledge and experience in caring  for a patient with mental problems (r=0.329; P<0.01). These associations demonstrate that complementary knowledge is necessary. The respondents receive and in the future they would like to receive knowledge and information about care of the patients with mental health problems in the lectures, training courses, during practical work, internet, conferences, seminars, professional literature. However, a small proportion of respondents (24.2%) were taking part in these activities (Table 2). Naturally, this gives less chance to try to achieve adequate competence. A low percentage (30.5%) of respondents (Table 2), who were able to manage conflicts, and absence of statistically significant link between self-confidence adequately to care for the patients with mental health problems, and an increasing rate of conflicts (r=0.015; P>0.05) show that general practice nurses lack skills. One of most important factors describing nurses' knowledge and ability to care for the patients with mental health problems is undesirable events: 46.9% of respondents reported no undesirable events, whereas 53.1% of general practice nurses admitted this fact ( Table 2). The most common undesirable events (60.3%) were runaway from inpatient clinic, injury followed by runaway (29.4%), and suicide (10.3%). More than half (57.0%) of nurses stated that the above-mentioned threats mostly occurred at night; 78.9% of respondents reported that they informed the next shift about changes in patient's behavior. Less than one-third (28.9%) of respondents indicated that these undesirable events were due to an unsuitable environment in the department for such group of patients; 27.3%, due to the conditions arising from patient's actions; 21.9%, due to limited time of nurses; and 18.8%, due to a lack of staff. Only a small proportion of respondents (3.1%) believed that these undesirable events might be caused by insufficient competence of personnel. The nurses evaluating the problem of undesirable events pointed out that they would like more training (29.7%), adjusted environment of the department (28.1%), more staff (17.2%) and psychiatrist's consultations (25.0%) ( Table 2). Spearmen's rank correlation coefficient and chi-square test confirmed a link between help that the nurses would like to get and actions mostly influencing undesirable events (r=0.395, P<0.05; χ 2 =32.05, df=0.136, P<0.002). Since competence of nurses is determined by all three constituents such as knowledge, skills, and attitude (9), nurses' attitude toward to the patients with mental health problems was examined. Data of the study (Table 3) show a positive attitude of nurses toward to the patients with mental health problems. For example, 84.4% of respondents stated that these patients were provided with care as well as the others, interaction was not escaped (89.1%), and the patients were not subjected to laugh or offensive talk (75.0%). However, the principles of nursing were acknowledged only by 6.3% to 24.2% respondents (  (Table 3). This shows the tendency of conservatism and a lack of competence of workers.

Discussion
The prevalence of mental disorders among patients for the first time was analyzed in Lithuania in Antakalnis Outpatient Clinic and Departments of Gastroenterology and Therapy of M. Marcinkevičius Hospital in 1991-1992. For the first time in Lithuania, the study proved that the patients with somatic diseases needed psychiatric help. However, existing services in our country are not sufficient. The results of this study led to development of training curriculum for therapists and general practitioners with the main focus on diagnostics and treatment of dementia, depression, anxiety, and somatoform disorders (13). However, the study showed that the largest groups of health care workers interacting with patients more time -nurses -were ignored. Care of the patients with mental health problems in the somatic departments is an actual problem. The study carried out in the Klaipėda University Hospital revealed that a subjective evaluation of nurses about care of the patients with mental health problems was not sufficient because positive answers to most of the questions were given by less than 50.0% of respondents. This may be partly associated with the fact that a very small proportion of nurses during the last five years participated in training courses, conferences, and seminars on care of the patients with mental health problems. In the United Kingdom, the results of the qualitative analysis demonstrated that general practice nurses believed that they knew little about care of the patients with mental health problems (8). Our study showed that competence of the nurses was positively influenced by duration of employment, education. Knowledge of disease, particularly its symptoms, helps to understand what may happen -all this information presents a better opportunity to care for a patient and to prevent undesirable events. This was proved by a statistically significant positive link between ability to recognize symptoms of mental disorders, evaluate their influence on patient's behavior, and knowledge of how to interact with a patient with mental health problems. According to the other studies, learning is one of the means of obtaining knowledge. It is determined that the nurses are ready to learn although they do not believe that it may contribute to a better improvement of patients' care, and in their opinion, there should be more cooperation between somatic and mental health departments. Moreover, learning should be uninterrupted; Competence of nurses caring for patients with mental health problems hence, training on a continuing basis would be the most useful one; it is more convenient to get information when one needs it (14). The results of our study show that the nurses were willing to learn, have training in seminars, conferences, workshops. The biggest part of the nurses would like to get a psychiatrist's consultation on caring the patients with mental problems. According to the findings of studies, nurses get consultations from the specialists of the somatic departments, and thus, they can get help and advice how to care for the patients with mental health problems (8). Such service is not possible in the health care institution where our study took place for the reason that there is only one psychiatrist; thus, he is not capable of consulting staff of almost 40 departments. Problems arise when the nurses are not able to call a psychiatrist in the evening and at night. They pointed out that it was most difficult to assure patients' safety in the evening and at night (Table 3). This is because less staff is at the time and it is more complicated to care for the patients. This fact may create undesirable events (runaway from an inpatient clinic, injury, suicide). Our study detected a link between help to nurses and factors influencing undesirable events (r=0.395; P<0.05). This suggests the necessity of nurse's competence, an adequate policy and financing of health care. It would be useful to invest time and money in the prevention of undesirable incidents (9). The best way to do this is to invest in training and education of managers and workers (3). Training is necessary because nurses should be able to observe, predict, and prevent undesirable events, particularly, such as suicide. Very important prevention of suicides is to train the health care specialists how to recognize, evaluate a person with suicidal tendencies, to react in a suitable way and provide help. Interaction with a patient with mental health problems should be based on a clear understanding of his/her intentions, particularly, when there are risk factors encouraging suicidal behavior (15). Our study demonstrated that there were conflicts with the patients with mental health problems in the department. To predict a possible danger to a patient's and other persons' health and life is possible only partially. Nurses working in such environment often say that they experience hopelessness or lack of knowledge and skills. The participants of the study carried out in the United Kingdom stressed that caring for people with mental health disorders was emotionally exhausting and debilitating. Furthermore, it reduces self-respect, decreases satisfaction with their work, stress is experienced, commonly ho-pelessness occurs, which leads to a pretext for limitation of interaction with such patients (8). Our study in Klaipėda health care institution showed that the biggest part of general practice nurses would not like to care for the patients with mental health problems. The major part expressed their opinion that only mental health specialists should care for these patients; therefore, it is in agreement with our society's opinion that persons who were diagnosed with mental health disorders are not able to make the decisions about treatment, personal life, activities, and psychiatric service should be provided in special health care institutions. Thus, it is necessary to educate society and to form a positive attitude toward persons with mental illnesses. According to the Pope John Paul II, a society that only gives space to its fully functioning members is not a society worthy of a man (5). General practice nurses working in the Klaipėda University Hospital do not acknowledge enough the principles of autonomy, confidentiality, dignity, justice, and they deal with conflicts caused by the patients with mental health problems by means of medications. One study pointed out that in Lithuania about 85.0% of patients were administered drugs because of F4 group diseases (adaptation, anxiety, somatoform disorders) in comparison to 30.0% of the Norwegian patients. Such frequent administration of drugs may be explained by a low possibility of alternative treatment of "psychosomatic patients," lack of staff, which would be able to provide alternative treatment. Most patients needed psychological help and behavioral therapy (consultation, information, counseling, support) (16). Thus, general practice nurses should apply alternative treatment rather medication. Competent activity should be based on values, knowledge, critical analysis, and reflection.

Conclusions
Professional competence of the respondents is not at the level required. This may be associated with moderate professional knowledge of nurses, undesirable events (runaway from inpatient clinic, injury, suicide), insufficient acknowledgment of the principles in nursing, few opportunities to obtain knowledge and develop professional skills in conferences, seminars, courses.