1. Background

Mental disorders are one of the major burden of disease Worldwide ^[1] and mental disorders are on the increase due to economic crises, psychosocial problems in the country and the number of people needing psychiatric care has increased proportionately ^[2]. This increase in the incidence of mental illness in the communities could be attributed to the non-availability of community based psychiatry services and the inability of the mental ill clients to utilize the available ones ^[3]. Mental health nurses are one of the core healthcare providers that contribute effectively in the management of all mentally ill patients in the communities ^[4].

Psychiatric Nursing (PN) also called Mental Health Nursing (MHN) are group of nurses that specialized in mental health practice and who provide nursing care services to the mentally ill patients throughout the continuum of care ^[5]. MHN provide and promote mental health care through the framework of the nursing process to early detect any mental disorders, they use the tool of patient assessment, diagnosis, planning, intervention and evaluationof human responses to mental health problems and psychiatric disorders to meet the needs of the patients ^[6]. Mental health nursing provide comprehensive, patient-centered mental health care and outcome evaluation in a variety of settings across the entire continuum of care ^[6].

Community mental health (CMH) nursing is a sub-specialized area of mental health nursing related to prevention and treatment of mental illness, and rehabilitation of former psychiatric patients using organized community programs; it approaches patients through the resources of the community ^[7]. Furthermore, Community mental health practice involves support and treatments of people with mental disorders or mental health difficulties in a domiciliary setting instead of a psychiatric hospital ^[8]. CMH system of care is more accessible and effective, it lessens social exclusion, has less possibility for the neglect and violations of human rights that were often encountered in mental health facilities ^[9]. It enhances client strength in the same environment as the patient’s daily life creating an individually tailored care for the patient ^[10], it serves to meet the needs of the entire community rather than that of a single service, services provide include emergency services, education for children, follow-up for previously institutionalized patients, alcohol and drug abusers and out patients services. It provides network of services that offer continuing treatment, accommodation, occupation and social support which together help people with mental health problems to regain their normal social roles ^[11].

The evolution of community mental health practice began in 1882 at McLean Asylum in Massachusetts where the early nursing leaders such as Harriet Bailey, Euphemia Jane Taylor and Lillian Wald supported the movement for mental hygiene and advocated for community psychiatric nursing ^[12]. Consequently, the first psychiatric trained nurses worked in the community setting and attends to clients’ needs in their homes and neighborhood ^[13].

In Nigeria, CMH practice has gained increased importance in recent years. This is characterized by small number of health facilities and mental health professionals, with concentration of care in the relatively few available psychiatric hospitals and psychiatric units of some secondary and tertiary health facilities ^{[14, 15]}. Likewise, with increase awareness among the public led to increased patronage of the few psychiatric facilities causing overstretching to the available services most especially in other patients facilities ^{[16, 17]}. This has led to recent calls in the country for the emphasis on institutionalization in favor of deinstitutionalization as practiced in the Western countries ^{[18, 19, 20, 21, 22]}.

In many African societies, Nigeria in particular, the public has negative attitude towards people with mental illness ^{[23, 24]} and they believed thatpsychiatric illness is caused by familial defect or the 'handwork of evil machinations' (demons, evil spirits). These negative beliefs result in psychiatric patients being seeing as an outcast and people who should be quarantined ^[24]. Another common societal belief is that psychiatric patients are responsible for their illness, especially when it is an alcohol and/or substance related problem. This stigmatization denies psychiatric patients the empathy and understanding traditionally bestowed on the sickpatients in African society. ^{[10, 11]}. These attitudes and beliefs against mental illness equally, heightened interest in deinstitutionalized system of care for persons with mental illness necessitated increased need for their social and occupational rehabilitation ^{[25, 26, 27]}.

The integration of mental health concept by World Health Organization (W H O) into primary healthcare programs as the 9^th component is an attempt to infiltrate the services of mental healthcare into communities for the benefit of every one and the mentally ill clients ^[28]. Effective implementation of WHO concept efficiently provide primary mental healthcare to patients seeking mental health services in a wide range of delivery settings and overall, promote universally selected and preventive mental health interventions ^[29]. However, community-based care is supported by literature, as a model for accessing and facilitating full participation and integration of service users within their community ^[30]. It is considered as a good practice for providing care to individuals experiencing acute mental health difficulties in the least restrictive environment, with the minimum disruption to their lives. In the majority of cases, service users and careers prefer community treatment ^[31].

To determine the perceptions of Nigerian mental health nurses towards community mental health nursing practice in Nigeria.

2. Methods

The study was carried out at the Annual National Scientific Conference of Association of Psychiatric Nurses of Nigeria (APNON) held at Federal Neuropsychiatric Hospital, Baranawa, Kaduna, Kaduna State between Monday 27^th to Friday 31st July 2015. APNON is an association of all psychiatric nurses in Nigeria under the umbrella of National Association of Nigeria Nurses and Midwives (NANNM). APNON Annual Scientific Conference was first inaugurated in the year 2001. The conference has been an annual event adapted to congregate all mental health nurses all over the nation to come up with ways of improving the standards of practice of psychiatric mental health nursing in Nigeria and to increase patients’ satisfaction through quality mental health nursing care.

This is a cross-sectional descriptive study design involving all Nigerian mental health nurses.

A total of 135 mental health nurses among the 200 attendees of 2015 APNON conference in Kaduna, Nigeria who gave consent to participate were recruited for the study. The participants were recruited using availability and purposive sample technique.

Data were collected using a structured questionnaire developed by the researchers from review of relevant literature on community mental health nursing practice. The researchers submit a research proposal to seek for permission and introduction from the authorities of the association to carry out the study and a written informed consent of each participant was obtained..

Data analysis was done using SPSS version16.0 for windows. Descriptive analysis was computed using dependent and independent variables, Mean and Standard Deviation, while test for significance was determined using Chi-square (χ2) and p-value set at P=0.05.

3. Results

More than half (54.8%) of the studied participants were females and most (45.0%) of them were between the age of 31 to 40 years. All participants have dual nursing professional qualifications or more. Participants working experience shows that 74.1% of them had spent between 1-10 years in practice as registered mental health nurses, with a mean years of experience of 11.1±7 years. Majority (62.3%) of participants were within the rank of Nursing officer and Assistant Chief Nursing officers. More than two third (77.9%) of the participants worked with tertiary health facilities and a quarter (25.4%) were from North central followed by 23.1% who were from northwest zone where the conference was held.

Table 1. Socio-demographic characteristics of participants

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Figure 1. Important of community mental health nursing practice

Figure 1 above illustrates that majority (88.0%) of participants affirmed that the practice of community mental health nursing is very important to the mental health nursing and as well as the patients.

Table 2. Perceived practice towards community mental health nursing

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Table 2 above shows that nearly six in every ten (59.1%) of participants perceived that they did not practice community mental health nursing at their various place of work and nearly all (99.3%) the studied participants perceived that creating annex hospitals and posting mental health nurses to the communities will significantly reduce the problem of mental illness.

Table 3. Participant’s perceptions on the advantages of community mental health nursing practice

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Compliance with drugs (60.7%) was identified by the participants as one the major advantages of practicing community mental health nursing practice (Table 3), followed by reduce stigma(57.8%), distance to hospital(46.6%) and transportation problems(45.9%).

Table 4. Perceived goals of community mental health nursing practice

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Table 4 above shows that overall 114 (100%) of participants perceived that community mental health nursing practice will promote mental health through early detection of mental disorders and the same portion 108 (100%) of them credited support for the involvement of patients families, friends and community in their care. In a related development, majority 105 (98.1%) of participants indicated that community mental health nursing practice will lessen patients anxieties towards mental illness.

Table 5. Perceived impediments to community mental health nursing practice

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Perceived factors hindering the practice of community mental health nursing are presented in Table 5 above. Nearly (62.2%) of participants established that lack of substantive policy do prevent them from practicing community mental health nursing. others factors reported include work load (47.5%) and resistance from mental health nurses due to limited staffing (45.1%).

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Figure 2.Ways to improved community mental health nursing practice in Nigeria

Figure 2 above elucidates that creating enabling policy for community mental health nursing practice 116 (86.0%), attending workshop/conferences 71 (52.5%) and enforcementof the practice by hospital and training institutions will improved community mental health nursing practice 71(52.5%).

Table 6. Association between selected socio-demographic features and participants' perceptions on community mental health nursing practice

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Table 6 presents factors associated with participants' opinions on community mental health nursing practice. Significantly, participants workplace geopolitical zone (p=0.000) and workplace (p=0.010) had important influence on the important of community mental health nursing practice to the nurse and patient and the practice of community mental health at their different place of work while professional qualification and years of experience did not have any significant with the selected socio-demographic features.

4. Discussion

Community psychiatric practice otherwise known as community mental health practice has been advocated in recent years. But this has been limited by small number of healthcare facilities and mental health professionals, with concentration of care in the relatively few available psychiatric hospitals and psychiatric units of some general and teaching health facilities ^{[14, 15]}. The importance of community mental health as a network of services that offer continuing treatment, accommodation, occupation and social support helps people with mental health problems to regain their normal social roles ^[32].In addition, good quality community-based services have been shown to be the most effective form of mental health care ^[33]. This has been the perception of the participants in this study.

Fernando ^[34] reported that the concept of deinstitutionalization of mental health care is to modify negative attitudes people has towards people with mental illness. A study ^[35] further corroborated this assertion that, nearly a third (32%) of the participants held that people with mental illness ware best treated in their home environment. As such, the practice of community mental health among mental health nurses therefore becomes paramount. In agreement with this, our study established that a good number (88%) of the Nigerian mental health nurses declared that the practice of community psychiatric nursing is very important to the mental health nurse and as well as the patients. Related to this, nearly all (99%)of the participants agreed that creating annex hospitals and posting mental health nurses to the communities will significantly reduce the problem of institutionalizing mental health care and nearly six in every ten (59%) of them reported that they did not practice community psychiatry nursing at their various place of work. Participants’ geopolitical zone (p=0.000) and workplace (p=0.010) had significant influence on the importance attached to community psychiatric nursing practice, as perceived by the nurses.

All the participants reported that community psychiatric nursing practice will promote mental health through early detection of mental disorders and they all supported the involvement of patient’s families, friends and community in care. Similarly, majority (98.1%) of participants indicated that community psychiatric nursing practice would lessen patient’s anxieties towards mental illness. These findings are similar to another study ^[11], which found that community mental health practice involves the support and treatments of people with mental disorders in a domiciliary setting instead of a psychiatric hospital. In addition, it provides network of services that offer continuing treatment, accommodation, occupation and social support which together help people with mental health problems to regain their normal social roles ^[8].

Participant’s opinions on factors hindering the practice of the community psychiatric shows that nearly 62% of participants established that lack of substantive policy do prevent them from practicing community psychiatric nursing. Other factors reported include workload (48%) and resistance from mental health nurses due to limited staffing (45%).Majority (86%) of the participants elucidated that creating enabling policy for community mental health nursing practice, attending workshop/conferences (53%) andenforcement of the practice by hospital and training institutions will improved community psychiatric nursing practice (53%).

5. Conclusion

In spite of the acknowledged, important of CMH practice to nursing profession and the patients, most the mental health nurses submitted that they were not practicing it at their various place of work. However, there is urgent need to explore ways to stimulate all levels of government (and their partners) to initiate or activate policies in favour of community mental health is paramount.

6. Study Limitations

Only a limited number of Nigerian mental health nurses attended the conference due to the security and sponsorship challenges in the country and employers respectively. Thus, the findings in this study could not be generalized.

Acknowledgement

The authors wish to thank Mr. Stephen Duniya of Federal Neuropsychiatric Hospital Barnawa Kaduna and Mrs. Taiwo Damilola Oluwafemi who participated in the data collection process. The comments of Mr. Emmanuel Ejembi Anyebe of Research and Training Unit, School of Nursing, Ahmadu Bello University Teaching Hospital, Zaria is genuinely acknowledged.

Conflict of Interest

The authors declared that they have no conflicting interest.

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