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The World Health Organization report Atlas: Nurses in Mental Health 2007 was launched on 11 September 2007 with a 7 country videoconference followed by a 2 week on-line global discussion. The following is the summary of the launch. I. Atlas: Nurses in Mental Health 2007 Project Atlas was developed by the World Health Organization’s (WHO) Department of Mental Health and Substance Abuse to raise public awareness of the inadequacies of existing mental health care resources and the inequities in their distribution at the national and global level. This project achieves this goal by collecting and compiling national data and distributing it at the global level. The latest publication in this series, the Atlas: Nurses in Mental Health 2007, was a joint project with WHO and the International Council of Nurses (ICN). This report provides global information on the current status of nurses in mental health. The three major recommendations are: Recognize nurses as essential human resources for mental health care Ensure that adequate numbers of trained nurses are available to provide mental health care Incorporate a mental health component into basic and post-basic nursing training II. The IBP Knowledge Gateway The Implementing Best Practices (IBP) Knowledge Gateway was developed by WHO/UNFPA/USAID and the partners of the Implementing Best Practices Initiative to bring individuals and groups together at the global, regional and country levels to exchange, communicate and share knowledge on health issues. This system supports virtual Communities of Practices and has been specifically designed for use in countries with poor connectivity. The IBP Knowledge Gateway current has 5100 members registered to 81 communities. The Mental Health Community of Practice was developed for this global discussion. It can be accessed at http://my.ibpinitiative.org/public/mentalhealth III. Videoconference The Atlas: Nurses in Mental Health 2007 was launched on 11 September 2007 with a seven country videoconference involving 133 participants from: Amman, Jordan; Queensland, Australia; New Delhi, India; Nairobi, Kenya; Geneva, Switzerland; Manila, Philippines and Brazzaville, Republic of Congo. The keynote address was given by Her Royal Highness Princess Muna Al Hussein, Jordan. Her Royal Highness urged health care professionals from around the world to join the Mental Health Community of Practice and actively participate in the 2-week On-line Global Discussion Forum. She challenged the public by stating: "I entrust you with the responsibility to share what you know and what you know works. I urge you to give of your time, to seek available expertise to learn from others lessons, to be open to new ideas, to seriously connect, and to 'dare to care'." Dr. Shekhar Saxena then gave a brief overview of the Atlas, focusing on the three recommendations note above. Five countries were then asked to share in-country experiences in mental health nursing. Lucila Espinosa, Chief, Nursing Services, from the Philippines shared information about programs for improving mental health nursing education. Richard Gagna Limando, Regional Programmes Director, Advanced Nursing Studies Faculty, Aga Khan University of East Africa discussed mental health nursing development in Tanzania. T. Dileep Kumar, President, Indian Nursing Council and Nursing Adviser, DGHS shared experiences on practice issues in mental health nursing. Kim Foster, Deputy Head of Schools, Cairns, School of Nursing, Midwifery and Nutrition, James Cook University in Australia discussed regulation issues. Finally, Da’ad Shokeh’s, Secretary General of the Jordanian Nursing Council shared experiences with mental health nursing in Jordan. The launch was supported by the WHO Department of Mental Health and Substance Abuse, WHO Department of Human Resources for Health, International Council of Nurses, WHO Department of Reproductive Health and Research, Partners of Implementing Best Practices Initiative, and the Global Alliance for Nurses and Midwives. IV. Global Discussion Following the videoconference a 2 week on-line global discussion was initiated to discuss the challenges and share successes in providing effective mental health care in resource poor settings. The global discussion was very active; there were 615 participants from 80 countries. The discussion from each week will be summarized separately as there were different themes and different experts for each week. The first week of discussion was initiated with the following questions: How can we advocate for improved mental health care in low and middle income countries? What are the limitations that make it more difficult for doctors and nurses to provide appropriate mental health care in low and middle income countries? What has been done and what could be done to improve this? What roles can nurses play in mental health care, which are at present denied to them? This week of discussion was supported by an expert panel of Dr. Shekhar Saxena, Coordinator, Mental Health: Evidence and Research, WHO, Dr. Tesfamicael Ghebrehiwet, Consultant, Nursing and Health Policy, International Council of Nurses (ICN), and Dr. Margaret Grigg, Senior Nurse Adviser, Melbourne, Australia. The first day of discussion was very active as there were 25 contributions from 9 countries. There were 96 contributions for the week. The major themes discusses during the first week were the roles of the mental health nurse, education and curriculum recommendations, and barriers to care, including stigma and lack of access to effective mental health care. The themes for the second week of discussion were led by the following questions: What are the examples of nurses providing effective mental health care in low resource settings? Are there innovative training programs for doctors and nurses to give them the needed knowledge and skills for mental health care? Should nurses be allowed to prescribe/continue the prescription of psychotropic medicines especially in countries where there are very few doctors and psychiatrists? The second week of discussion was supported by an expert panel of Dr. Jean Yan, Chief Scientist, Office of Nursing and Midwifery, WHO, Dr. Thomas Barrett, Senior Mental Health Consultant, WHO, and Dr. Margaret Grigg, Senior Nurse Adviser, Melbourne, Australia. Throughout the two weeks of discussion Dr. Frances Hughes, Dr. Edilma Yearwood, Dr. Kim Foster, Dr. Ian Norman and Dr. Kathy Hegadoren joined the discussion as guest experts. The second week of discussion had 67 contributions. The major themes of the 2 week discussion were roles of the mental health nurse, education and curriculum, barriers to care, innovative recommendations, prescribing rights and personal experiences. Roles of the Mental Health Nurse Overall the community agreed that mental health nurses typically have multiple roles in addition to direct patient care. Mental health nurses often have administrative and policy making responsibilities. However, there is little recognition of the importance of mental health care and the critical role of nurses in providing this care. Rakesh Mishra from India made these comments “we need a global leadership to disseminate the evidence of mental health problems. We have to influence big stockholders and especially the national political economy. We have to compel them through our evidence to make policy relevant to need based approach. This is much more relevant in low and middle income countries." Markos Tesfaye from Ethiopia notes that "nurses could play a tremendous role in mental health care in low and middle income countries where they run many of the primary health care centers. Mental health care does not need sophisticated technology or several years of high level training. The majority of patients can be helped at primary care. Nurses in the first place do receive little training in mental health. However, they could play (a)role in diagnosis and treatment of common mental disorders, recognition and referral of severe mental disorders, and education of the public to reduce stigma against the mentally ill." Education and Curriculum There was an overall agreement that both basic and graduate nursing curriculum should expand to include more exposure to mental health issues. Additionally there were suggestions to standardize curriculum globally and to assure a balanced curriculum that will include multidisciplinary influences. Scott Cowcher from the US shared his personal experience with curriculum building in Cambodia: "I recently completed working for 2.5 years in Cambodia as Psychiatric Nurse Coordinator/Trainer for the Cambodian National Mental Health Program (Partnered with Norad, University of Oslo and IOM). Cambodia is a poor country with an average government wage around $40 a month. My role in this capacity building project was to coordinate the training of psychiatric nurses in a post basic curriculum. The project had been in existence since 1994 and has to date trained approximately 26 psychiatrists and 40 psychiatric nurses. What I really enjoyed about contributing to this project was that previously trained Cambodian Nurses and Doctors became involved in the future training of psychiatric nurses and psychiatrists. Skills appeared to be transferred within the country, with help from external experts but with the intention of the Cambodian people building their capacity to sustain future training of health professionals with aim of increasing independence and integrating mental health into the country's health system. This approach also allowed clinicians to begin to build cultural knowledge about mental health issues that are culturally relevant to Cambodia". Barriers to Care The community shared numerous experiences about barriers to effective mental health care. The most common barriers addressed were the stigma associated with mental illness and resource shortages in low and middle income countries. Lud Thomassen from Zambia notes the following barriers to care: “I have been reading the postings every day. Today I feel ´low´ realizing how much education is available in other countries. Here in Zambia locals are so poor that they can hardly afford secondary school for their children. After that it depends on scholarships what kind of education one can continue. If there is not enough money for university then you go to nursing school or to teacher training. Very often your future depends on the money and you are not free to choose what you want to study. A lot of nurses and teachers are therefore not motivated. It is just a job with job security. We all know that if your ´heart is not in your work´ that you can't be effective in mental health nursing. On top of that we face the problem of ´brain drain´. Nurses are recruited by other countries (neighboring countries but also U.K. and Australia) and leave us without... And that leaves the mentally ill people of course at the complete bottom end of the receiving line.” Innovative Recommendations The community participants were asked to share their innovative solutions to the challenges of providing effective mental health care. Participants’ responses included examples of innovative curriculums, unique public education programs, and productive partnerships. Dr. Edilma Yearwood, one of our guest experts, shared an innovative method to deal with stigma. In Canada, “Mental Illness Awareness Week is an annual national public education campaign designed to help open the eyes of Canadians to the reality of mental illness. It is coordinated by the Canadian Alliance on Mental Illness and Mental Health, with support from all of its member organizations. This campaign includes the Faces poster and bookmark campaign. This year's Faces include a child with bipolar disorder, a man and a woman of Aboriginal heritage as well as persons of Caucasian heritage.” Shoba Raja from India describes a successful model used in low resource settings: “Our program [BasicNeeds] uses the model of "Mental Health and Development" which aims to address treatment, economic/livelihoods and capacity needs of the affected individuals and their families. For the delivery of treatment services we work in close partnership (formal and also informal in some cases) with government health services at the primary care level, bringing us in close contact with psychiatric nurses. We have found the cadre of Community Psychiatric Nurses (CPNs)to be extremely dedicated and committed, even as they work in such tough circumstances and challenges - many of which have been articulated in these discussions - dealing with tangible issues such as poor resources, poor availability of psychotropic drugs as well as the more intangible ones such as facing stigma, lack of career growth opportunities etc. A great contribution to our efforts comes also from the cadre of community level workers. These are people from the communities who were already working with the health services for other programmes such as HIV, Malaria, reproductive health etc. who now also work with persons with mental illness in their communities.” Prescribing Rights Overall the community agreed that properly trained nurses should have the ability to prescribe specific psychiatric medications. This belief is based on the assumption that increasing the access to psychiatric medications could significantly improve the quality of life for people with mental disorders. Community members recommended that nurses working within the community should follow standard protocols. Our expert Dr. Margaret Grigg shared this comment with the community: “standard protocols can be simple to develop, and from a regulatory perspective easy to implement. In low income countries standards can be an affordable and effective strategy to improve access to medication provided that they are combined with education and supervision.” Shared Experiences Many community members used this discussion forum to share their personal experiences and challenges faced while providing mental health services. Julian Eaton from Nigeria shared his in-country experience in developing community mental health services in Nigeria: “I have been working to develop community mental health services in Nigeria for the last 4 years, and have found the Community Psychiatric Nurse to be the central figure in establishing practical services that work. We found that providing some training in mental health to Primary Health Centre (general) nurses did not result in them delivering care to many clients with mental health problems. They were unable to gain adequate skills, and they did not prioritize mental health in their busy schedules. Only by having a dedicated nurse and investing in developing village-based community health workers (volunteers) did we start to really find the people we knew had need in the community. The main issues in keeping the quality of service high has been to provide regular supervision and training, providing transport (motorcycles) for community work, and to run the Drug Revolving Fund (DRF) ourselves (i.e. a Nigerian NGO partner). This may be a uniquely Nigerian factor (where many drugs on the open market are fake, and DRFs run in government always collapse).” Donnahae Rhoden-Salmon from Jamaica shared some successful experiences in providing mental health services in low resource settings: “Jamaica has had a successful mental health programme despite the lack of resources. This is due mainly to the following factors: 1) The recruitment and training of committed individuals; 2) The implementation of a community based mental health programme; 3) The establishment of a special unit dealing with mental health in the ministry of health; 4) The attempt by the government and other stakeholders to destigmatize mental illness. Community Mental Health was introduced to Jamaica in the 1960s. Its main focus was prevention. This includes all forms of prevention including primary, secondary and tertiary prevention. One of its components was to train nurses to become mental health officers. These persons would live in the community in which they serve and offer advice and treatment to individuals affected by mental illness. They would also conduct clinics usually under the supervision of a visiting psychiatrist. To ensure the success of programmes like these and to overcome challenges a concerted effort must be made by government and other stakeholders to: 1) Recruit committed individuals in these programmes for often they have to work in substandard conditions; 2) Ensure proper remuneration to staff members; 3) Ensure suitable working conditions; 4) Encourage the families to be a part of the care of their family members; 5) Steadfastly follow up all patients that come to the clinic; 6) Maintain an efficient referral system; 7) Initiate and maintain public education about mental illness; 8) Expose members of staff to new forms treatment including medication if even limited knowledge; 9) Limit hospital stay for the care of the acute mentally ill to not more than twenty eight days so that persons are not alienated from their family members for a lengthy period of time; 10) Provide some support to family members” At the end of the second week we noticed a decrease in responses and relatively few comments from the low and middle income countries. Dr. Shekhar Saxena sent out a call to action to ask community members from these countries to actively participate in the discussion and share their experiences and opinions. In response to this call to action, Dawit Wondimagegn Gebreamlak responded “I recently had a discussion with mental health nurses in rural Ethiopia, before I mention about some of the difficulties the nurses mentioned I would like to state that one of the most difficult problem we have is the lack of the information technology. The nurses are out there working hard as ever but there is no way that they can access this information. Most of them work in remote areas no Internet let alone light is available, so if they do not comment please try to understand that in the situation they are working there is simply no access to the information. Having said that here are some of the problems mentioned by three mental health nurses in a focus group discussion we had: 1. Lack of acceptance by other health professionals probably because of low level of awareness about mental illnesses; 2. Lack opportunity for Carrier development, like further training to a degree level and so on because there is only a diploma programme; 3. Lack of continuous medical education programme to update their knowledge and skill; 4. Lack of professional support groups to share experience and get moral support; 5. Lack of representation in regional health bureaus' resulting in marginalization and neglect by authorities; 6. Lack of basic psychotropic medications like chlorpromazine and amitriptiyline, sometimes for months, resulting in lots of relapse which led to frustration. I would say this was probably the most stressful problem for the nurses. It resulted in serious pessimism and low morale at work. We all know that WHO had made a huge difference in the treatment of tuberculosis by making anti TB drugs available for free. To my knowledge the conventional medications are not expensive drugs. Could we think of a similar or better approach like the anti-tbs to make it available and sustainable?” Global Discussion Overview The following is a technical summary of the participants’ experiences formulated by the Johns Hopkins University INFO Project. Of the 615 subscribers to this forum, 65 responded to the survey, an 11% response rate. Respondents came from 24 countries and represented a wide variety of organizations including NGOs, health organizations, and academic and research groups. Most people (42%) participated in the forum primarily by e-mail, although 37% participated online and 21% used both approaches. About 12% of the participants who went online did report having some problems logging on to the IBP Knowledge Gateway, while the other 88% did not. Thirty-seven percent of the evaluation respondents posted a message on the forum. About 50% of the respondents downloaded and read some of the materials recommended or discussed, and another 39% said they planned to do so. The majority of respondents felt that involving a guest panelist in the discussion each week was useful (90%). Most people liked receiving a single, digested e-mail each day (83%), although 17% said that they have preferred to receive the e-mails as they were posted. Most survey respondents were very satisfied (72%) or somewhat satisfied (25%) with the content of the discussion. Most respondents felt there was the right amount of discussion (71%); 19% felt that there was not enough and 10% felt that there was too much discussion. Almost all (90%) said the forum definitely or somewhat met its goal of exploring how to close the gap between what is needed and what is currently available to reduce the burden of mental disorders worldwide and to promote mental health. Many respondents (44%) forwarded some of the postings to other people. Twenty-nine percent of respondents reported already having used resources or practices discussed in the forum in their work while an additional 46% plan to use them in the future. Participants shared some examples of how they have used or are planning to use this information: - Preparing seminars with nurses about the mental health topics discussed. - Sharing new information and ideas with fellow staff members and contributing towards the universality of community mental health programs. - Incorporating new information into health programming in Kenya. - Preparing mental health surveys and publishing related articles. - Electronic networking. - Communicating with discussion participants regarding potential training programs in Afghanistan. - Increasing cultural awareness. - Broadening the awareness of the limited resources some nurses have and demonstrated their resourcefulness in order to provide their services. - Sharing information and viewpoints at the Australian College of Mental Health Nurses Forum. Participants had a number of useful suggestions for improving future discussions including: - Discuss further the effects of harmful effects of drug and shock treatment as well as non-medical approaches to behaviors of the mentally ill. - Focus on the whole team of primary care professionals providing mental health services rather than solely nurses. - The forum needs to continue long term to produce real effective results. - Easier access to the discussion resources. - Involve consumer groups. - Comments that are less wordy. - Digests, while helpful, may not have been necessary each day. - Allow belated responses. - Localize some topics to regions of the participants. - Longer duration of forum. - More publicity and advertisement. - I think this discussion was well-done. No suggestions at the moment! V. Next Steps Immediately following the conclusion of the On-line Global Discussion four sub- communities were stared. Dr. Michael Rice, Associate Professor & Coordinator: Psychiatric Specialties, College of Nursing and Healthcare Innovation, Arizona State University began two sub- communities: The Mental Health Advanced Practice Nurse Community of Practice and the Mental Health Technology Solutions Community of Practice. The advanced community currently has 66 members and continues to have very active discussion. The technology group has 18 members and there are bi-monthly discussion posts on this topic. Dr. Edilma Yearwood, Assistant Professor, Georgetown University maintains and leads the Mental Health of Children and Adolescents Community of Practice and updates and initiates discussions on a monthly to bi-monthly basis. There are currently 32 members in this community. The Women’s Mental Health Community of Practice is lead and maintained by Dr. Kathy Hegadoren, Professor, University of Alberta. This community currently has 21 members and has had minimal activity. VII. References Atlas: Nurses in Mental Health 2007. Geneva, World Health Organization, 2007.
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