Further Training, Educational Needs and Work Challenges of Mental HealthNurses in Greece before the Completion of the Psychiatric Reform

According to mental health care reform in Greece, psychiatric hospitals had to be closed down for their greater part and units would have been integrated into general hospitals, during the year 2014-2015. The psychiatric care reform is not yet completed. Due to the economic recession of the country, the last 5 years, the Greek government has asked from the European committee an indefinite extension and financial support for the implementation of the psychiatric care reform program. When the reform will take place, psychiatric nurses will be a part of a larger team of nursing staff working in psychiatric outpatients units. The aim of the study was to identify the nurses’ educational needs for further training concerning the outpatient provision of care. A questionnaire-based study was conducted among 164 psychiatric nurses working in two major psychiatric hospitals to be closed following the reform. A descriptive analysis was applied to describe nurses’ educational needs for further training concerning the outpatient provision of care. The majority of nurses noted that the most important issue in everyday work was effective communication with the client and patient’s symptoms management. The nurses thought they lacked management abilities to effectively deliver evidence-based care in community settings. Problems between the health care team (disagreements, miscommunication and violent episodes) and lack of time and personnel were the causes of additional stress in their work. The results have shown that nurses were adequately prepared for clinical care but there is a need for further training especially in law issues and the nursing role in the community settings. Introduction Since 1983, Greece has had a number of 10-year National plans for mental health services, co-funded by the EU. The last National plan originated in 1998 was called ‘Psychargos’ and was divided into three phases: Phase A: 1998-2001; Phase B: 2002-2006 and Phase C: 20062015. The main objectives of this programme were: i. The deinstitutionalization of the remaining 3000 long-stay patients, ii. The development of 616 mental health services including community-based structures, rehabilitation units and iii. The closure of the remaining mental hospitals. (5/9 psychiatric hospitals by the end of 2006 and the remaining by the end of 2015). According to mental health care reform in Greece, psychiatric hospitals had to be closed down for their greater part and units would have been integrated into general hospitals, during the year 2014-2015. The psychiatric care reform is not yet completed. Only phase A and B are completed. Due to the economic deprivation of the last 5 years, the Greek government has asked from the European committee for Sci Forschen O p e n H U B f o r S c i e n t i f i c R e s e a r c h Citation: Koukia E, Papatriantafyllou JD (2018) Further Training, Educational Needs and Work Challenges of Mental Health Nurses in Greece before the Completion of the Psychiatric Reform. J Psychiatry Ment Health 4(1): dx.doi.org/10.16966/2474-7769.128 2 Journal of Psychiatry and Mental Health Open Access Journal questionnaire with 5 point Likert-like scales and consists of three parts: I. Questions around daily work II. Questions along coping with stress and workload III. Questions concerning the need for further training An ad-hoc questionnaire was formed to record participants’ sociodemographic and professional characteristics. We analyzed results through descriptive analyses. Results The sociodemographic characteristics of the sample are reported in table 1. The final sample consisted of 164 registered nurses. Seventy one (43.2%) were males and 93 (56.7%) were females, with a mean age of 30.3 years (SD=5.2 years; range 21-52 years). The mean years of work in a psychiatric setting were 5.2 (SD=5.2 years; range 1-23 years). Questions concerning daily work The majority of nurses considered as “very important” building a relationship with the client (96.9%), communicating with the client (96.9%), planning and documenting care (59.7%), working with doctors (61.6%) and supporting the client during the personal crisis (84.8%). They also saw as “very important” stabilizing clients (64.6%) and supporting the client to manage their health needs (60.3%). A significant number of nurses recorded they felt poorly qualified in planning and documenting care (68.3%), administrative duties (57.9%), supporting the clients in recognizing their potentials and strengths (40.8%) and supporting the clients in self-determination to all decisions concerning their own life (39.0%) (Table 2). Coping with stress and workload Nurses found extremely difficult (6) or very difficult (5). Having the responsibility for clients in a crisis (39.0%), “switching-off after work (46.3%), managing aggression (100%), managing suicidal behavior (164%), not having enough time when working with clients (81.1%), having problems with the team (35.3%) and having problems with “superiors” 76.8%) (Table 3). Questions concerning the need for further training The topics that nurses wished to cover in a training program were assessment (47.5%), methodology and models (100%), the legal background (92.0%), professional role in mental health nursing (100%), reflective practice (62.2%), managing crisis (100%) (Table 4). documenting the role of nurse identified six main areas. Day-to-day management of clients, working with clients, working with carers and their families, crisis work for both existing and first-time contacts, and liaison and advocacy work were the areas of the CMHNs’ role expansion [4]. In Greece, mental health professionals have in general positive views of the movement of psychiatric care reform, from psychiatric hospitals to extramural services. However, there is no previous study to provide information on the views and needs of nurses working in psychiatric hospitals and how adequately nurses feel they can respond to their role expansion. Aim of the Study The aim of this study was to: Identify nurses’ educational needs for further training concerning outpatient provision of care when working with mental health clients. Objectives of the present study were to: • Evaluate nurses’ practices in the daily routines • Identify nurses’ coping strategies against stress and workload • Identify nurses’ needs for further training Subjects and Methods Research design The study was a wider implementation of a Leonardo Pilot Project (Lifelong Learning Programme) that was carried out in 2009 by Epikouros-DIAN. Training and management Activities in collaboration with other countries. A descriptive research design was used in the study. The goal was to identify nurses’ training needs and develop new curriculums for training concerning outpatient psychiatric care in the face of the psychiatric reform. Setting The present study was carried out in the two major psychiatric hospitals in the Athens Metropolitan area, which are to be closed. These two hospitals have inpatient units and extramural facilities as well. These two major psychiatric hospitals have a capacity of 500 and 400 beds respectively. The two large psychiatric hospitals employ both registered nurses (RNs) with a 4-year education and nurses assistants (NAs) with a 2-year education in nursing. A total of 746 nurses are working currently in the two hospitals (260 registered nurses and 486 nurse’s assistants). Subjects Questionnaires send to all nurses from the personnel list. The response rate represents 63% of the total registered nurses (n=164). The sample of the study consisted of 164 full-time registered nurses (4-year education) who worked 37.5 hours per week-three rotating-in inpatient wards in the two major psychiatric hospitals. Ethical consideration Ethical approval for the survey was obtained from hospitals ethics committees. Head nurses of each department were personally contacted by the research team about the aim of the study. Assurances were given concerning confidentiality and anonymity. Statistical analysis Data were collected using the WAP/Vocational training community based Psychiatric nursing questionnaire. This is a self-administered N% Sex Males 71 (43.2%) Females 93 (56.7%) Age x=30.3 ± 5.2 Years of work x=5.2 ± 5.2 Position Registered nurse: 4-yr preparation (university degree) MSc – PhD 4 (2.4%) 3-yr preparation-psychiatric nursing specialty(technological college) 4 (2.4%) 3-yr preparation (technological college) 156 (95.1%) Table 1: Socio demographic characteristics of the sample (n=164). Sci Forschen O p e n H U B f o r S c i e n t i f i c R e s e a r c h Citation: Koukia E, Papatriantafyllou JD (2018) Further Training, Educational Needs and Work Challenges of Mental Health Nurses in Greece before the Completion of the Psychiatric Reform. J Psychiatry Ment Health 4(1): dx.doi.org/10.16966/2474-7769.128 3 Journal of Psychiatry and Mental Health Open Access Journal How important are the following aspects in your daily work? How good are you qualified for these areas? Areas of activity On a scale of 6-1 On a scale of 6-1 Very important-unimportant (%) Very good-poor (%) 6 5 4 3 2 1 6 5 4 3 2 1 Building a relationship with your client 97 3 15 10 22 25 11 16 Managing and reflecting distance and proximity 23 27 22 16 11 24 6 10 21 26 34 Motivating basic self-care 32 22 26 21 52 39 4.1 3 Supporting / advising clients in organising their daily life 48 27 12 13 17 22 33 12 4.8 11 Communication with clients 97 3 17 15 11 15 20 22 Monitoring Clients 41 59 13 41 34 11 Planning and documenting care 60 40 12 20 68 Nursing assessment 16 41 21 21 16 14 16 18 20 16 Implementing prescribed medical care 15 16 16 23 18 17 100 Working with doctors 62 27 11 22 15 17 10 16 20 Working with therapists and social workers 9.1 16 7.9 17 27 28 35 15 7.9 13 11 17 Administrative duties 29 21 15 15 9.7 9 27 15 58 Stabilizing clients 35 65 17 20 48 16 Supporting the clients to manage their health problems 46 60 37 15 11 9.7 0.7 20 Supporting the 


Introduction
Since 1983, Greece has had a number of 10-year National plans for mental health services, co-funded by the EU. The last National plan originated in 1998 was called 'Psychargos' and was divided into three phases: According to mental health care reform in Greece, psychiatric hospitals had to be closed down for their greater part and units would have been integrated into general hospitals, during the year 2014-2015. The psychiatric care reform is not yet completed. Only phase A and B are completed. Due to the economic deprivation of the last 5 years, the Greek government has asked from the European committee for

Results
The sociodemographic characteristics of the sample are reported in table 1. The final sample consisted of 164 registered nurses. Seventy one (43.2%) were males and 93 (56.7%) were females, with a mean age of 30.3 years (SD=5.2 years; range 21-52 years). The mean years of work in a psychiatric setting were 5.2 (SD=5.2 years; range 1-23 years).

Questions concerning daily work
The majority of nurses considered as "very important" building a relationship with the client (96.9%), communicating with the client (96.9%), planning and documenting care (59.7%), working with doctors (61.6%) and supporting the client during the personal crisis (84.8%). They also saw as "very important" stabilizing clients (64.6%) and supporting the client to manage their health needs (60.3%).
A significant number of nurses recorded they felt poorly qualified in planning and documenting care (68.3%), administrative duties (57.9%), supporting the clients in recognizing their potentials and strengths (40.8%) and supporting the clients in self-determination to all decisions concerning their own life (39.0%) ( Table 2).

Questions concerning the need for further training
The topics that nurses wished to cover in a training program were assessment (47.5%), methodology and models (100%), the legal background (92.0%), professional role in mental health nursing (100%), reflective practice (62.2%), managing crisis (100%) ( Table 4).
documenting the role of nurse identified six main areas. Day-to-day management of clients, working with clients, working with carers and their families, crisis work for both existing and first-time contacts, and liaison and advocacy work were the areas of the CMHNs' role expansion [4].
In Greece, mental health professionals have in general positive views of the movement of psychiatric care reform, from psychiatric hospitals to extramural services. However, there is no previous study to provide information on the views and needs of nurses working in psychiatric hospitals and how adequately nurses feel they can respond to their role expansion.

Aim of the Study
The aim of this study was to: Identify nurses' educational needs for further training concerning outpatient provision of care when working with mental health clients.
Objectives of the present study were to: • Evaluate nurses' practices in the daily routines • Identify nurses' coping strategies against stress and workload • Identify nurses' needs for further training

Research design
The study was a wider implementation of a Leonardo Pilot Project (Lifelong Learning Programme) that was carried out in 2009 by Epikouros-DIAN. Training and management Activities in collaboration with other countries. A descriptive research design was used in the study. The goal was to identify nurses' training needs and develop new curriculums for training concerning outpatient psychiatric care in the face of the psychiatric reform.

Setting
The present study was carried out in the two major psychiatric hospitals in the Athens Metropolitan area, which are to be closed. These two hospitals have inpatient units and extramural facilities as well. These two major psychiatric hospitals have a capacity of 500 and 400 beds respectively. The two large psychiatric hospitals employ both registered nurses (RNs) with a 4-year education and nurses assistants (NAs) with a 2-year education in nursing. A total of 746 nurses are working currently in the two hospitals (260 registered nurses and 486 nurse's assistants).

Subjects
Questionnaires send to all nurses from the personnel list. The response rate represents 63% of the total registered nurses (n=164). The sample of the study consisted of 164 full-time registered nurses (4-year education) who worked 37.5 hours per week-three rotating-in inpatient wards in the two major psychiatric hospitals.

Ethical consideration
Ethical approval for the survey was obtained from hospitals ethics committees. Head nurses of each department were personally contacted by the research team about the aim of the study. Assurances were given concerning confidentiality and anonymity.

Statistical analysis
Data were collected using the WAP/Vocational training community based Psychiatric nursing questionnaire. This is a self-administered

Discussion
The study reported a high response rate of the registered nurses, indicating a reasonable generalizability of findings, though this is limited by the non-random sample selection. The study included only registered nurses and excluded nurses' assistants who play an important role in delivery of care in mental health hospitals in Greece because registered nurses will play a centered role in community care settings.
The sample was representative for three reasons. These two major psychiatric hospitals are to be closed and nurses' educational background is based on the same nursing schools and the majority of nurses had received a minimum training in mental health nursing.
In order to interpret correctly the findings of this study-except the educational background mentioned above we have to consider that hospitals operate with a major shortage of trained professionals, and nursing profession in the current economic situation in Greece is a low income profession. The fact that personnel shortage has a negative effect on the delivery of care is consistent with previous study [5].
Community mental health nurses' role is extremely important in promoting community care. A study concerning CMHNs' role focused on six main areas which included the day-to-day management of clients, working with carers and their families, crisis work for both existing and first time contacts, as well as liaison and advocacy work. [4]. Previous studies showed that the workload of community mental health nurses is increased by the greater complexity of needs of community mental health clients and the main themes were relating to staffing and workforce issues, clients' characteristics or needs, regional issues, and the impact of the health-care system [6].

Questions concerning our daily work
In line with World Health Organization's objectives to promote recovery-oriented care [7] research has shown that nurses need support in order to provide assessment and documentation of psychosocial interventions. Nursing interventions in primary care is fundamental to quality of care. Nurses in this study felt inadequate in planning/ documenting care (68.3%), and in administrating duties (57.9%) [8]. It has to be noticed that there are no protocols or care plans for nurses to follow in Greek mental hospitals. Concerning documenting of care   nurses has to make decisions based on cognitive continuum theory and exhibit high situation awareness in every clinical case which will lead to a safe clinical care in a community setting [9].

Sci Forschen
They also considered it very important to build a relationship with the client (96.9%), communicate with the client (96.9%), and support the client during personal crisis (84.8%), stabilize clients (64.6%) and supporting the client to manage their health needs (60.3%). A study concerning psychiatric nurses' and patients' opinions for suicidal patients has shown that communication with the patients is the most important element in patient care [10]. Additionally nurse-patient relationship may enhance the patient's health and strengthen patient's own resources through recovery [11]. Previous studies have identified the intensification of the workload of CMHNs. Relating to staffing and workforce issues and clients' characteristics and needs is of high priority in the community services [6].

Coping with stress and work load
Nurses found extremely difficult (6) or very difficult (5) and strenuous almost all aspects of the topics mentioned in this part of the questionnaire; the responsibility for clients in crisis (39.0%), "switching-off after work (46.3%), managing aggression (100%), managing suicidal behavior (164%), not having enough time when working with clients (81.1%), problems with the team (35.3%) and problems with "superiors" (76.8%). Community Mental health nurses are in danger for high levels of stress and burnout because they combine three major stressful components: high work overload, dealing with mental health problems and in many cases they face a decrease in job satisfaction [12]. A study concerning mental health nurses emotional wellbeing have demonstrated that is linked to professional practice and organizations must address nurses' emotional needs [13].
Nurses play a key role in the management of patients in crisis. Nurses reported their difficulty in managing aggression and suicidal behavior. In a crisis, nurses possibly did not have the time for an appropriate risk assessment. Previous study has shown managing anxiety, aggression and intervening in crisis to be of great importance in everyday practice [14]. Additionally studies have shown that mental health practitioners need a specific training in the implementation of care plans e.g. harm reduction in self harm psychiatric patients in order to feel capable to handle serious situations [15]. Nurses' attitude towards self harm patients is very important and a number of studies have indicated that nurses have a negative attitude which can improve with the help of education [16].
Community work demands high level of preparation for the confrontation of critical incidents given the fact that nurses act usually autonomously. Previous study in Greece has shown that nurses in Greece have inadequate preparation to work in community mental health [17,18]. A study across seventeen European countries has shown that there is a lack of clarity on matters concerning violence management. The theme of prevention seems to be of top priority in nursing training [19]. Additionally nurses' responses revealed the need for specific protocols for the management of aggressive patient. Others countries like Spain developed protocol with exact guidance in order for the patient to be treated in the least coercive manner and nurses to feel safe and capable to deal with it. [20]. Patients' aggression is a major health problem and nurses are often called to manage effectively aggression and its consequences. Previous study found that psychiatric nurses reported low levels of access to learning opportunities and receiving support, lack of clinical guidelines and inadequate autonomy concerning managing aggression which leads to a great dissatisfaction in the workplace [21].
In the community setting nurse have to keep a balance between continuous observation of the patient and taking a risk in decision making. Good decision making require a sufficient collaboration with the patients and the therapeutic team [22]. It is of major importance that nurses referred to "problems with the team" and "working with doctors" as important and strenuous in their everyday practice. Community care is based mainly on continuous care delivered by interdisciplinary teams who functions in patient centered way to  ensure quality of care and the transition between hospital and primary care [23]. Community mental health nurses have more autonomous roles and the relationship with clinicians is a major component of this role [24].

Sci Forschen
Mental health nurses in the community settings will have to play a consultant/liaison role using the concept of patient-centered nursing care. Concerning the remaining themes in the questionnaire like managing and reflecting distance and proximity, supporting clients in organizing daily life, promoting and supporting a client's socialnetwork and relationship with family and supporting the client in recognizing their potential, strengths, self-determination and decisions concerning their own life we show a diversity in the answers. Diversity in the results is attributed in the different levels of nurses' education in Greece and in the fact that they act without autonomy since the law is not clear concerning nurses' intervention framework. Nurses have inadequate preparation for functioning autonomously and for applying intervention techniques. Nursing continues to be dependent on the medical profession's authority [25].

Training program
The findings of the present study revealed that nurses are unprepared for community care services. Given the fact that community mental health nurses must be prepared for their future role, a specific defining of what "nurses' role in community settings" means is essential. A study was tried to identify the components of the community based mental health role and found that clinical contact with clients, administrative and care coordination activities were very important [26].
Currently a number of training programs in hospitals address to nurses in order to increase nurses' job satisfaction, communication skills, team relationships and decrease job-stressors and psychological distress [27,28]. Additionally a number of education programs for mental health professionals appeared to lead in increased professionals' recovery-promotion behaviors, recovery-oriented practice skills and knowledge [29][30][31]. Training programs that will integrate evidencebased practice into community nursing practice are also needed [32]. have shown that a training program may have no effect unless the content and the duration are sufficiently examined [33]. Total sample of the Greek Mental Health Nurses mentioned specific deficiencies in their daily work like managing aggression, self-harm and suicidal behavior that need to be considered in a future training program. The management of patient in crisis demands specific guidelines developed by a national center for nursing, nurses' training, the implementation of these clinical guidelines and the assessment of possible results integrating service users views (patient and family) [34].

Limitations
The non-participation of other health professionals in this study could be a limitation. Nurses reported "problems with the team" and "problems with superior" so future interventions could be more broadly integrated into therapeutic team everyday practice; focused on team's relationships and cooperation. The findings of this research cannot be generalized to nursing as a profession but represent a snapshot of the Greek psychiatric hospitals currently in existence.

Conclusions
This study assessed the mental health nurse's practices, coping strategies and training needs. Nurses reported high stress and work overload. Nurses have inadequate preparation for functioning autonomously and for applying intervention techniques. Since current nurses will staff future extramural services and will play an important role in patients care, it was deemed important to develop training programs based on these results in order to educate nurses how to implement care policies in evidence based clinical practice. The conclusion is that the existing nursing situation seemed to be unprepared to implement and facilitate community care.