Inductive thematic analysis was used to analyse data collected based on the objective of the study. The results included the characteristics of study participants as well as the four main themes of the study. The four main themes were derived from the data collected which included; reducing stigma by CPNs; religion and CPNs, self-motivation by CPNs and reduction in-home visits.
Characteristics of study Participants
Three (3) males and ten (10) females participated in the study, with their ages ranging from 26 to 60 years. All of them were CPNs with various academic and professional qualifications. Six (6) of the participants were registered mental health nurses, with bachelors’ degrees from the university. Three (3) were registered mental health nurses and the remaining four (4) were enrolled mental health nurses.
Reducing Stigma by Community Psychiatry Nurses
Most of the participants (10 out of 13) were stigmatised because they cared for patients who were mentally ill. The poor perceptions and attitudes that society held caused the CPNs a great deal of stress. Yet, the CPNs were committed to their jobs and employed several strategies to help them withstand the negative attitudes of community members.
In the interest of the patients’ integrity, the CPNs hid their identity from the public during home visiting. This was also to ensure privacy and confidentiality, as well as to ward off gossip about their clients. The disclosure was based on the discretion of the CPNs and was only done when it was necessary. Most of the participants said that they disguised themselves during home visits as a strategy to mitigate the effects of the stigma associated with their work. A participant narrated:
“When you are a client and I’m in a mufti (casual wear) and come to visit you, nobody would know I am a nurse. You see, society brands them as mad people; which our clients detest this attribution so much. Not wearing uniforms when visiting clients is a way of providing privacy. So when I come in mufti, no one recognises me as a nurse…” (Participant 2)
A 60-year-old CNP shared her reasons for not wearing a uniform:
“Our reason for wearing mufti is because of the negative thought about mental illness. The clients or relatives feel ashamed that nurses in uniform do visit them because of their condition. For us CPNs we protect our clients such that people might not say that there is a mad person in this house and psychiatric nurses are following him or her. We protect our clients such that we take them as relatives or friends whom we visit…the second issue is to protect our clients and make ourselves not to be so conspicuous, glaring or display ourselves in public such that our clients will feel respected in a way that public eyes will not be following us that, nurses are following this mad person or coming to visit them…” (Participant 3)
All participants (13) agreed that hiding their identity during home visiting of mentally ill patients was a way of protecting the privacy of their patients and making their clients comfortable. Mentally ill or so-called “mad people” are not respected in the Ghanaian society and therefore CPNs reportedly wear mufti rather than uniforms so that community members do not necessarily know why the person was being visited.
A CPN shared her rationale for hiding her identity:
“…but we do explain to them, as to why we come in house attire. We do not wear uniforms because we don’t want our identity to be known by the community members that we are CPNs so that people don’t think there is a mental illness wrong with that person. Some people agree and others to do not. So, we think it is the stigma attached to mental illness and that is why some of us do that”. (Participant 6)
Some of the participants (9 out of 13) highlighted additional measures they took to further ensure that no one knew that their clients were patients who had mental health problems. This was done in order to avoid stigmatisation. One of the measures was to make sure they knew exactly where their patients lived so that they avoided asking people. Not all streets in Ghana are labeled and it was common practice to ask people for direction when one could not find his or her bearings. In an individual interview, participant 9 described her strategy to locate her patients:
“We don’t wear uniforms when we are going on home visits because of the stigma. We wear only mufti. What we normally do, is that when we find our clients especially on Tuesdays at the Accra Psychiatric Hospital, we try to find out if we have clients within our catchment area, then we take their landmarks for purposes of home tracing…we even take telephone numbers. So, all this information help us to get to the client’s house without asking for direction from strangers. This usually helps us to prevent stigma”.
Almost all the CPNs (12out of 13) used landmarks to locate the houses of their clients. They also collected and kept telephone numbers of relatives so they could ask for directions from relatives, and not community members. Furthermore, they did not wear their name tags, but rather kept them concealed in their bags and only showed them to relatives of their clients.
Religion and CPN
Some of the participants (7 out of 13) said that they used religious beliefs to console themselves concerning the challenges they encountered in their work. The CPNs trusted God as the source of grace, help, and abundance and suggested He worked as a mediator. The CPNs reported that they did all they could to help the patients and expected that God would reward them:
“But the bible says give and it shall be given unto you. So, sometimes we take consolation that when we give, our Father also sees us through the challenges we grapple within our lives. So, we find consolation in the bible. We do that for some of these patients, anticipating a reward from God, not the client”. (Participant1)
Another participant shared her belief in God:
“Most of the things we do are demoralising because it is difficult for our authorities to accept whatever we propose or suggest to them to work with. But we don’t work on our authorities but with the families and those concerned. Our work is demoralising, the challenges are there and by the grace of God we are managing and we contain them”.
Self-Motivation by CPNs
Despite the multitude of challenges faced by the CPNs, they continued to care for the mentally ill in their various communities. Participants (13 out of 13) were self-motivated to meet the demands of the work though they were faced with hazardous work environments such as slaps and attacks by patients. The CPNs reported that they were not recognised for the work they do, even though they thought their work came with dangers and weariness. They were reportedly demoralised for the lack of recognition and job satisfaction. Even though some of them felt sad and hurt, they could not complain because in their view no one gave them a listening ear. They tried to ignore their inner sentiments of sadness and moved on with their work. Some were invigorated seeing their clients doing well. Others hoped that one day their work would be appreciated.
“…if you really have that kind of heart…if you are the tolerant type, you can continue to work in the midst of attacks (slaps) by your patients. You can’t say because the client slapped me or the client poured urine on me, I won’t go and deliver care to him/her. Some people might not go, but if you really have the interest in the job and the client, you will by all means go…” (Participant 12)
Others expressed negative emotions regarding their job as CPNs but continued to render care by encouraging themselves:
“It is painful but all the same we have taken it as our job so we try our best to do it. This is because if no one is giving you any form of motivation, you don’t put your mind on it. You have to give yourself another time so that it doesn’t hurt you more. But if it hurts you, you can’t go out every day to help clients. But, if you are able to send your hurts somewhere for a remedy, you will still be visiting your clients at home”. (Participant6)
Another participant said:
“Well, I have not regretted that I have done this work and have gotten into this condition. I’m happy that God has given me life to continue. I accept the situation as it is in the meantime and hope that something better will come someday”. (Participant 9)
Participant 5 hoped to be noticed one day since she continued to do her best in terms of educating the public and conducting home visits to check on clients. She indicated, however, that she was happy that some of the clients were in good health:
“We are still striving, still doing our part and hope to be noticed one day. I’m still doing my best through education, visiting my clients. So, I take it cool and I’m happy at least some of my clients are doing well”. (Participant 5)
Reduction in Home Visits
Participants (8 out of 13) mentioned that sometimes they had to reduce the number of home visits as a means of dealing with the challenges they encountered in terms of financial and human resource constraints and lack of transport:
“What we usually do is to restrict the number of visits that we embark on normal working days due to financial constraints. But we do increase the number of visits when we have student nurses around…because we have had a lot of students so we can do more visits within a short time frame…” (Participant 12)
One participant noted:
“Yes, yes if you are supposed to visit about 10 clients a day and there is no money, we can only do about 4 or 5 because that is how far the money can take you and it brings about reduction in-home visits and subsequently it is the client that suffers”. (Participant 4)
A participant said:
“At times, it’s like you draw your own itinerary with regards to what you want to do with the clients but because there is no T & T, you have to leave this and cover a different thing because the means are not there for you to get to that place because, at the end of the day, you are supposed to work”. (Participant 11)