“We try our best to offer them the little that we can” Coping Strategies of Ghanaian Community Psychiatric Nurses: A Qualitative Study CURRENT STATUS:

Introduction Addressing strategies of coping among community psychiatric nurses (CPNs) could help increase an individual’s ability to cope effectively and as a result, reduce experienced levels of stress. It is known that the level of work stress experienced by CPNs is remarkably high, because psychiatric nurses face more intense relationships with their patients, trying to prevent self-harm, and most at times face challenging situations with aggressive patient behaviors in the working environment. Therefore, the study aimed to explore the coping strategies employed by CPNs during healthcare delivery in the community. Methods An exploratory qualitative study design using an interpretative approach was employed. A total of 13 CPNs were purposively sampled, and data gathered through individual interviews using an interview guide. The interviews were audio-taped, transcribed verbatim and analyzed thematically, describing some of the coping strategies employed by CPNs in Ghana.


Introduction 3
Coping strategies are definite efforts that constitute behavioural and psychological acts that people adopt to master, accept, lessen or reduce stressful situations [1,2]. With effective coping strategies, one is able to produce better psychological and emotional adjustment to a persistently stressful event [3]. Coping encompasses changing cognitive and behavioral efforts to handle specific internal and/or external stresses [1]. Coping is therefore defined as a process of change to manage, reduce or tolerate specific stresses that individuals perceive as potentially threatening to their well-being [4,5].
Nursing, in general, is associated with extreme pressure, because of the highly demanding, challenging, and stressful nature of the professional characteristics [6]. Work-related stressors in nursing are related to increased workload, potentially violent patients, role conflict, and when there is perceived low levels of support, be it social or professional [7,8]. A plethora of studies reports that psychiatric nursing is a stressful profession [1,5,[8][9][10][11][12][13][14]. Carson et al. [15] documented that nurses working in the community had poorer psychological health, higher job satisfaction and lower levels of depersonalization. In a study, across six European countries, Hill et al. [16] found that community mental health teams (which included nurses) experienced more exhaustion than their inpatient counterparts. Such professionals often work alone, receive less structural support and have fewer opportunities for role confirmation through contact with others undertaking similar tasks.
Consequently, nurses should adopt strategies to cope with stress so as not to run the risk of developing stress states. These strategies, called "coping strategies," are the means used by individuals to overcome stressful and difficult circumstances, and according to some authors those "coping strategies" have been defined as a set of cognitive and behavioral approaches used by individuals in order to handle specific situations (internal or external) [2].
Due to the strenuous work environment it prudent that Psychiatric nurses manage their stress and stay healthy to provide the best of care they can for their patients. It is, therefore, essential for Psychiatric nurses to nurture good physical and mental health; initiating techniques of coping that will strengthen their ability to cope effectively [8]. This, in turn, will reduce the levels of stress and burnout they experience [14]. Therefore, understanding how community psychiatric nurses (CPNs) cope with job-related stress is an important workplace strategy, not only for the nurses themselves but also for the organizations they work for and eventually the patients who are receivers of their care [8].
Observation of the CPNs in Ghana shows that they are faced with numerous challenges. These challenges include being provided incorrect home addresses of their patients, lack of transportation, assaults by patients, shortage of staff, low morale, and non-compliance to medications by the patients, leading to patient relapse and readmissions [17]. Despite these numerous challenges, limited empirical studies have emphasised the importance of CPNs in Ghana [17]. Also, there exists little or no reported evidence on the various coping strategies these professionals adapt to effectively discharge their duties. The objective of this study, therefore, was to explore the coping strategies used by CPNs in the discharge of their duties. Uncovering these coping strategies will help Ghanaian CPNs to adopt to the hazardous work environment which will further help the advancement of community psychiatric nursing practice.

Research Design
This exploratory qualitative research design used an interpretative approach to gain an in-depth understanding of the coping strategies employed by CPNs when delivering care in the communities within the Accra metropolis. This design was suitable for the study because it gave the nurse researcher the opportunity to focus on gaining a deeper understanding of an experience and to explore the meaning of experiences related to issues that have implications for nursing practice and research [18].

Study Setting And Population
The study was conducted in the Accra metropolis which is the political and administrative authority for the city of Accra. The data was collected within the month of January 2013. The target population for the study was CPNs working in the community psychiatric units and polyclinics in the Accra metropolis. About 60% of CPNs in Ghana work in Accra and all the CPNs in Accra metropolis meet weekly for a case conference.

Inclusion And Exclusion Criteria
The inclusion criteria for the study were all CPNs who had graduated from the Psychiatric Nurses Training College and had more than three years of working experience. Community Psychiatric Nurses with less than three years of working experience and those working outside the Accra metropolis were excluded from the study.

Selection Of Participants
A purposive sampling method was employed to recruit 13 participants from 6 sub-metro districts (Ayawaso, Ashiedu Keteke, Okaikoi, Lekma, Ablekuma, and Osu-Klottey) in Accra. Participants were recruited through a regional in-service training department of the Accra Psychiatric hospital for all CPNs in the region. At least 2 participants were selected from each of the 6 sub-metro districts. Data saturation [19] was reached with thirteen interviews.

Data Gathering Instrument
A semi-structured interview guide was used for data collection. The interview guide was developed by reviewing related literature on coping strategies by community psychiatric nurses [10,13,15,20,21].
The interview guide consisted of participants' demographic characteristics and their coping strategies being used in the community for mental healthcare. The principal questions asked were; "What do you do to over the challenges that affect your work? How do you cope with the challenges that affect you?" The interview guide was pre-tested with 5 participants outside the study area. Interviews were audiotaped with the participants' consent. Fieldnotes of emotional expressions were taken consisting of salient points during the interviews and observations of non-verbal communications, were noted during the interviews. Restructuring of the interview guide was then made after the pre-test for clarity and simplicity. A co-researcher and expert in psychiatric nursing reviewed the interview guide to determine its relevance to achieve the aim of the study. The purpose of using a semi-structured interview was to generate in-depth and sincere data that will lead to a deeper understanding of the issues [22].

Data Collection And Analysis
The study recruited 13 participants based on the inclusion and exclusion criteria. Individual interviews were conducted each day for 13 days at a side office of the Accra Psychiatric hospital to ensure privacy during interviews. Face-to-face in-depth interviews were conducted and also, probing questions were used when needed in order to elicit hidden information from the participants. The interviews which lasted between 30-60 minutes were tape-recorded. Each interview session had a moderator and two assistant moderators. The moderator led the interviews and kept the discussion flowing. The first assistant moderator operated the audio tape recorder and took comprehensive notes, the second assistant moderator responded to unexpected interruptions.
After each interview, the audio recordings were transcribed verbatim by FYO. In order to ensure accuracy of transcription, the transcripts were returned to participants for feedback and possible corrections to be made. The transcripts were read and reread by three (FYO, AA, PA) of the authors to ensure acquaintance with the data. The audio recordings were frequently referred to, to enable easy interpretation of the answers in their actual context. The transcripts were coded by FYO and supervised by PA to identify emerging themes that were discussed by the entire research team. Data were manually analysed thematically using the 6-step approach outlined by Braun and Clarke [23], a carefully developed thematic code frame. The 6 phases of thematic analysis were; 1. Familiarizing yourself with your data, 2. Generating initial codes, 3. Searching for themes, 4. Reviewing themes, 5.
Defining and naming themes, 6. Producing the report.

Ethical Approval
The Institutional Review Board of Noguchi Memorial Institute for Medical Research of the University of Ghana, Legon approved the study (NMIMR-IRB CPN 022/12-13). Approval letters were submitted to the administrators of all of the community psychiatric units of the various health facilities. Verbal and written consent was obtained from all participants prior to individual interviews. Interviews were audio-recorded, with the approval of each participant. Participants were assured of confidentiality.

Results
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: 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…" 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.

Discussion
The findings of this study highlight various forms of coping strategies adopted by Ghanaian community psychiatric nurses working within the Accra metropolis. Though they had various forms of challenges confronting them while delivering care for clients in the communities, they adopted the following coping strategies namely; reducing stigma, religious beliefs, self-motivation and a reduction in the number home visits for the client.

Reducing Stigma by Community Psychiatry Nurses
Reducing stigma was a coping strategy employed by CPNs in managing some of the difficulties encountered in their practice. Some of the CPNs mentioned that they wore mufti (casual wear) to visit clients as a disguise or a cover of their profession. Most CPNs mentioned that their reason for wearing mufti was due to the negative thoughts about mental illnesses in most Ghanaian settings and the stigmatisation of the mental health person and family caregivers [24]. Not wearing a uniform was a way of protecting the clients so that people would not say that there is a mental patient in a particular house for which CPNs are following up on him/her. A recent study in Ghana reported that clients and professionals were stigmatised because of the uniforms the professionals wore [24]. Not wearing a uniform in this study was a way of assuaging any bad feelings of the relatives who might misconstrue the nurses' intentions for visiting them. This was also an attempt to reduce public suspicion and stigma towards the client and the family. In other words, this current finding is different from the study findings of Corbiere, Samson, Villotti, and Pelletier, which sought to provide a more complete and exhaustive perspective on the whole range of potential strategies to fight stigma in Canada by considering the perspectives of different stakeholders [25]. Corbiere, Samson, Villotti and Pelletier, in their study identified 15 categories of strategies to combat the stigma that were identified from them verbatim, for example, sharing/encouraging disclosure. The results from their study highlighted the need to pay more attention to the concept of disclosure of mental disorders in the process for destigmatisation [25], but the current study's findings sought not to disclose client identity in order to reduce stigma at the community level. The disparity in the study findings might be due to different study environments, cultural beliefs, and understanding of the mental illness.

Self-Motivation by CPNs
Participants also indicated that self-motivation was a coping strategy they used to deal with the demands of their work. Some participants stated that they are sometimes assaulted by patients but still continued to do their work. Other participants mentioned that they did not have the desire of going for home visits these present times unlike when they started work as CPNs. Community Psychiatric Nurses continued to self-motivate themselves to deliver the best form of care they could even though they faced several challenges. Our study finding is similar to Wang, Kong, and Chair, who described three methods frequently used by nurses to cope with stress at their workplace, which one of the methods used was optimistic (positive mindset, positive attitude, positive associations) [26]. The current study participants were truly optimistic to deliver care to their clients no matter the situation. They had that positive inner drive known as self-motivation. The current study finding is also congruent with Bonsu and Salifu Yendork [24], where professionals (including CPNs) reported only being intrinsically motivated, considering the current state of mental health system in Ghana.

Much of their inner drive was informed by their knowledge and achievements. Existing research by
Roberts, Asare, Mogan, Adjase, and Osei, [27] also supports the current study finding, where they indicated that there were instances where professionals got motivated by the outcome of their patients' recovery. It is realized that most of the nurses in the current and previous studies engaged in positive problem-focused coping: where they develop the ability to strategise in order to address the reason for the stress. And this coping strategy is considered to be the most effective way of dealing with workplace stress [14]. This implies that CPNs continue to offer health services in spite of the constraints of their work through intrinsic motivation.

Reduction in Home Visits by CPNs
It was also found in this study that a reduction in the number of home visits was another measure CPNs adopted to deal with the challenges of their work. Some participants mentioned that because of financial constraints they usually regulate the number of home visits needed to be done. Some participants indicated that lack of transport or transport allowance did not allow them to cover areas that they had planned to visit. Findings from Fagin et al., showed that Psychiatric Nurses used an inadequate approach to managing stress by unconsciously or consciously distancing themselves from the cause of stress [21]. This finding by Fagin et al. [21] is consistent with the current study finding where community psychiatric nurses reduced the number of home visits due to stress. This coping strategy of reducing home visits or distancing themselves from sources of stress has negative repercussions on the therapeutic relationship between the psychiatric nurse and the clients [21]. This means that CPNs must be adequately resourced in terms of finance and transport to enable them to visit their clients wherever they are in the community. Considering the insufficient salaries paid to CPNs at the end of every month which would not be able to sustain the high financial demands from their immediate family and relatives, neither to talk of using the same insufficient salaries for community home visits.

Religion as coping CPNs
The present study finding revealed participants used religious beliefs to a coping mechanism to console themselves concerning the challenges they encounter in their workplace. The CPNs trusted God as the source of grace, help, and abundance and suggested He worked as a mediator in the midst of a challenging work environment. The current study disagrees with Bonsu Salifu Yendork [24], where the mental health professionals (including nurses) never used religion as a coping mechanism amidst of the job stress. The current study finding supports a study conducted among Iranian by Salaree Zareiyan, Ebadi, and Salaree [28], where they used religion as a coping strategy in order to mitigate a stressful work environment. The participants reported that nursing care was a religious duty, so they worked for spiritual reward than its financial aspect. Therefore, they do not feel tired much because the objective is God's satisfaction

Conclusion
Coping strategies among community psychiatric nurses are essential for both individuals and organisations. Thus, it is essential that CPNs should acquire personal-mastery coping strategies such as a reduction in the number of home visits, reduction of stigma, the use of faith to motivate themselves in the face of abuse and trauma meted out by clients. The coping strategies adopted by CPNs in the current study were not to only help them deliver care, but also as a way of protecting the clients so that people would not tag them as 'mental patients'.

Recommendations
Based on the findings of this study, the following recommendations were made: Community Psychiatric Nurses should be encouraged to identify more effective ways of dealing with the challenges at their workplaces to ensure effective delivery of healthcare.
Community Psychiatric Nurses should be adequately motivated to ensure effective community care.
Although coping strategies by CPNs is a significant topic area, very little research about this topic is available throughout the country, therefore further studies on coping strategies by community psychiatric nurses should be encouraged.

Consent to publish
Not applicable

Data Availability
The datasets used during this study are available from the corresponding author on reasonable request.

Conflicts of Interest
The authors declare that there are no conflicts of interest regarding the publication of this paper.

Funding
No funding for this study