Psychiatric Nurses in Uganda and the United States: Defining Their Mental Health Roles and Leadership Opportunities

This is a tale of two countries, each approaching the mental health needs of its citizens using the care of psychiatric nurses (PN) in strikingly different ways. The one, Uganda, founded in 1962, is a young country in an ancient land, rich in natural resources, but plagued by political despotism, civil wars, population displacements, and grinding poverty, all of which have wreaked havoc on many of its citizens’ mental health. The other, the United States (US), an almost 250-year-old democratic republic, also rich in natural resources, but free from ongoing violent civil wars, possessing the largest economy in the world, and providing a system of layered mental health supports for its citizens. The unique histories, cultures, policies, and resources of Uganda and the US form the backdrop of the challenges that each nation’s PNs tackle in an effort to provide mental health care to those who need it most.

Specialty

Although each country uses different monikers, PNs in Uganda and the US provide specialized care to both crisis and chronically oriented patient populations. As an emergent service in a low-income country, PN related care in Uganda relies on the World Health Organization (WHO) for its epidemiologic data, programmatic support, and clinical guidance. (Kigozi, Ssebunnya, Kizza, Cooper, & Ndyanabangi, 2010). While WHO (2011) data estimates that Uganda’s neuropsychiatric disorders contribute over 5% of its global burden of disease, research by Hall et al. (2014) cite prevalence ranges of mental illness as between 13-35% of the populations sampled. In resource depleted Uganda, the sheer numbers of citizens needing care is overwhelming, even to those PNs who dedicate themselves to their improved mental health.

For US populations, healthy life expectancies are also negatively and dramatically affected by mental health illnesses. WHO (2011) data estimates neuropsychiatric disorders contribute almost 31% of the its global burden of disease, with mental illness and poverty sharing mutually reinforcing and exacerbating links, including increased risks of suffering more diseases (such as HIV infection and diabetes) and negative social outcomes (such as stigma and prostitution). There are insidious connections between poverty, physical ailments, and mental illness regardless of continent, country, and culture (Kigozi et al., 2010; Leung, LaChapelle, Scinta, & Olvera, 2014; McLaughlin et al., 2012). PNs are uniquely positioned to provide critical primary care benefiting patient populations suffering from these often-overlapping conditions (Hanrahan, 2012; Zauszniewski, Bekhet, & Haberlein, 2012), and are especially capable implementing and monitoring mental care plans when other desirable resources are not available (Nankumbi et al., 2011). National politicians and institutions claim to promote healthy and prosperous environments, so understanding the specialized roles played by PNs in Uganda and the US requires more focus now than ever.

Regulatory Sources in Scope of Practice

The regulatory sources in scope of practice for PNs are substantially different in Uganda and the US. Each reflects their country’s political, economic, and cultural histories, as well as the roles taken by PNs and allied health care professionals.

Uganda’s Regulatory Sources

Uganda’s regulatory structure takes root in its ancient history as a land of tribal kings, as well as its recent British colonial past. It is highly centralized, functioning through a single national office, from which nursing practice standards are then administered in the following hierarchical fashion: (1) four geographic regions; (2) 111 politically designated districts; (3) hundreds more counties, sub-counties, and parishes; and finally (4) tribal units. Established in 1922, the Uganda Nurses and Midwives Council (UNMC) is the country’s regulatory body, acting under the umbrella of the Uganda Ministry of Education and Sports. The UNMC oversees the professional standards of general nurses and other nurses in a variety of specialized cadres, including Registered Mental Health Nurses (diploma bearing) and Enrolled Mental Health Nurses (certificate bearing).

US Regulatory Sources

Unlike in Uganda, the US regulatory structure associated with PNs is state focused, rather than nationally controlled. This result is likely sourced in the US’s founding political documents, which represent an ongoing “tug and pull” of national federalism versus state-oriented powers. It points to a framework where each state’s regulatory body maintains its independence, upholding professional standards to which all practicing individuals in that state must abide. For example, in the State of New Jersey, all nurses, including PNs, are regulated by the Board of Nursing, which is but a small part of the Department of Law & Public Safety, Division of Consumer Affairs. Each state’s authorizing laws, regulations, and administrative reach are distinct, therefore, working independently of other states and the US federal legal structure.

Scope of Practice

PN scopes of practice are distinct from one another in Uganda and the US. Each country’s history and health care systems dictate what is legally allowed, what is culturally expected, and what is personally accepted by PNs themselves.

Level of Autonomy

Uganda’s global deficit of trained health care workers is a primary impetus for providing increasing levels of autonomy for PNs’ so that they may deliver a greater scope and deeper levels of mental health care to patient populations. Nankumbi et al. (2011) describes a successful application of this aim within the scope of HIV prevention through a Johns Hopkins funded a therapeutic alliance between Makerere University College of Health Sciences and six nurse managed Kampala City Council health clinics. Seeking to streamline HIV care to target communities, “both to offer high quality care to patients and expand access to care with fewer workers,” the study highlights how by increasing autonomy in the decision making process, the nurses identified: (1) new opportunities for leadership and management; (2) closer monitoring of existing operations at the clinical level; (3) new stakeholder status in planning future operational improvements; and (4) immediate implementation of better direct service to patients in all modules. (Nankumbi, et al., 2011). This integrated nurse empowered HIV care deployment model serves as an inspiring template for similar studies in Uganda’s PN practice domains.

In the US, the level of autonomy practiced by PNs has been long established. After conducting a systematic review of the literature, Fung, Chan, & Chien (2014) concluded that PNs ably: (1) perform multifaceted roles and demonstrate significant results in managing clients with depression and psychological stress; (2) develop collaborative partnerships with non-mental health service providers; (3) streamline introductions to allied mental health providers that increase accessibility to those services; and (4) create systems enhancing the quality of inpatient care. These types of advanced nursing care practice in mental health settings is an established foundation of autonomy in governance, that helps PNs develop additional collaborative opportunities to provide cost-effective interventions in the US.

Global Leadership

In Uganda, PNs have not published evidence of their leadership in the policy-making aspects of the government’s initial steps towards implementing a comprehensive mental health policy. Although now playing an embryonic role in peer-reviewed studies on mental health topics, the dearth of published material on matters of global leadership in nursing reasonably suggests that PNs in Uganda, like their midwifery colleagues under the UNMC umbrella, have not gained sufficient traction to engage in sustained high level policy advocacy efforts, resources mobilization, or strategic leadership discussions. Apparently, the country’s lack of financial resources and weak institutional capacity are lingering determinants to PN’s historical lack of influence on the national political level.

By contrast, PNs practicing in the US display a rich resume of professional integration throughout the entire spectrum of medical care and can serve as a model of leadership for much of the developing world’s nurses. These hard won accomplishments are evidenced by the sheer volume of peer-reviewed PN-centric journals, including: (1) Journal of Child and Adolescent Psychiatric Nursing; (2) Journal of the American Psychiatric Nurses Association; (3) Journal of Psychiatric and Mental Health Nursing; and (4) Archives of Psychiatric Nursing. These and other publications are supported by a culturally diverse and passionate corps of the profession’s member driven organizations, including the American Psychiatric Nurses Association, the country’s primary voice of advanced practice nurse members. PNs in the US have and continue to demonstrate their significant voice in improving the specialty itself, as well as advocating for improved systems of care and treatment for persons with psychiatric disorders on all levels.

Health Relief Efforts

Perhaps the truest manifestation of PN leadership in the US is the ongoing “medical missions” many organizations deploy to Uganda. Many of these missions are faith based, where PNs and support staff are funded by both Catholic and Protestant private foundations in the US. This overtly religious-medical approach seems to fit well with Uganda’s legally sanctioned structure, which implements its mental health resources through both non-denominational and distinctly Christian based district hospitals.

Prominent non-denominational supports are provided by organizations such as Doctors Without Borders (DWB), and the American Psychiatric Nurses Association (APNA). DWB mental health care aims primarily to reduce people’s symptoms and improve their ability to function, using PNs and other clinically trained staff. One novel low-cost plan offered through APNA, “Pillows of Unrest,” is designed to be an easily implementable, culturally transportable, and clinically viable mode of assisting the mentally ill by promoting recovery through the arts. While the original purpose of the project was to provide information and to help remove discrimination against those with a history of mental illness, it provides multinational project management opportunities, whereby patients express and showcase their talents through artistic expression on donated pillowcases, a recognized supportive mode of recovery.

Barriers to Practice

In light of the enormous personal, familial, and societal costs mental illness causes, determining barriers to practice is critical. The five key barriers identified by WHO, (2013, December), that need to be overcome are: (1) absence of mental health as a public agenda; (2) the current structure of mental health services; (3) the lack of integration within primary care outlets; (4) inadequate human resources; and (5) lack of leadership. For purposes of this paper, only the most egregious category barriers in each country are outlined immediately below.

Uganda’s Barriers

Uganda’s history of violent political and tribally inspired retribution has wrought unimaginable tolls on its population, from which it still seeks to recover. The related devotion to propping up despotic central government figures has pulled from other human needs, including disease prevention, education, infrastructure, and provision for mental health supports. In the midst of ongoing grinding poverty, Uganda not only depleted itself of precious natural and human resources, but left deep residues of distrust, which will likely require decades of many people acting with great vision, passion, and compassion on many fronts to overcome.

The lack of adequate numbers of PNs to meet the mental health needs of its populations, are exacerbated by the structural chokeholds maintained by Uganda’s centralized educational and licensing structures. The Butabika School of Psychiatric Nursing (Butabika) in the nation’s largest city, Kampala, is presently the sole fully accredited educational facility for those wishing to become PNs. After graduation, administrative hurdles abound. Following one’s completion of requirements for PN diploma or certification, the UNMC (Uganda’s sole licensing authority) requires that each individual bring a specific set of original documents and sit for a personal interview with the “registration and enrolment committee, which normally takes place on the first Wednesday of the month.” This system may strive to ensure maximum candidate quality, but it puts an untenable clamp on meeting the mental health care needs of Uganda’s citizens.

The social and self-stigmatization of mental illness itself presents a formidable barrier to care in Uganda. Nsereko et al., 2011 details these roots as stemming from deeply held cultural beliefs that mental illness is due to supernatural causes. When tribal systems hold fervently to causal factors of “witches, curses and evil or ancestral spirits” (Nsereko, et al., 2011, p. 4), people rarely if ever seek assistance from medically trained PNs or psychiatrists. When traditional healers fail to meet community needs through exorcisms and tribally accepted medicines, the afflicted are often abandoned altogether, for fear that the disease will spread to its other members. (Nsereko et al., 2011). This sad result is not to suggest that tribal communities fail to care about those who exhibit signs of mental disability; rather, it highlights the enduring need to collaborate with traditional healers, and thereby earn the trust of these populations in order to support and better manage their mental health care needs.

US Barriers

While the US overcomes many barriers to care with technology leveraged educational and regulatory resources (including, for example, distance learning platforms, which often allow full credentialing via the internet), it also has difficult obstacles, including too few PNs to meet the needs in identified patient populations. The US enjoys having an incredible array of geographically disperse, world class institutions boasting world class instructors using the most modern of educational tools, modes, and methods. But the numbers of licensed PNs are perpetually short of delivering the quantity and quality of care required for best outcomes, even though “strong empirical evidence shows that the risk for adverse outcomes increases when nurses are spread too thin among patients” (Hanrahan, 2012). Unlike in Uganda, the US has the financial might, but has not exhibited consistent political will, to overcome this barrier. In this light, the endemic shortage of mental health nurses practicing in clinical settings seems particularly deplorable.

Access to care presents the other ongoing main barrier to care in the US. The Affordable Care Act (“Obamacare”) is in its own beginning stages of roll-out, and there is no reliable data to show how efficiently this access to care challenge will be overcome on a national basis. What is known is that so far, six million individuals have enrolled, and that politically supportive “Blue States” (California, New York, Illinois) have the lion share of enrollees, while staunch “Red States” (Texas, Oklahoma, Mississippi) have largely blocked implementation efforts. If this grand, experimental public/private health insurance recipe is supplied by a second fiscal year of private health insurer open market participation, then it may alleviate only some access to mental health care needs, based on those states which have devoted resources to the effort. (Beronio, Po, Skopec, & Glied, 2013). Like so much else involved in providing adequate mental health support to its citizens in need, this is a matter of political will and resource allocation, rather than a financially impoverished federal system of government.

Suggested Policy Changes and Revisions

No country’s system of care is immune from systemic shortcomings. The major issue is how best to effectuate the changes that are designed to reach the greatest number of people in the shortest amount of time. Decisions involving resource allocation, projected efficiencies, and desired outcomes are what shape these high-level policy discussions.

Uganda Policy Change

The only explicitly allied regulatory authority for nursing scope of practice, the Uganda Ministry of Health (UMH), acts as the national governing body for all of medical related practice. The UMH does not mention (even in passing) any mental health topics on its official government website. Uganda is in the nascent stages of providing bureaucratic supports in many disparate policy arenas, aiming to create, implement, and manage up to international standards of medical practice. One suggested policy change is to therefore establish within the UMH an explicit recognition that mental health sciences – including the practices of PNs - are indeed medical sciences, rather than solely palliative care practices. This purely structural change would not seem to require much financial allocation, and may over time lead to a lessening of the damaging social and self-stigmatization felt by those who need mental health care, as well as provide PNs with a basis upon which to understand and act on the deep opportunities for shaping the advancement of mental health care alongside their allied health care colleagues.

PNs themselves seem ideally situated to play a leadership role in driving policy changes in Uganda’s mental health structure. Both the current President and Ministry of Health rightly trumpet significant gains made in the prevention of HIV/AIDS in Uganda. Academics in Uganda itself recognize the intimate reciprocating relationship mental illness bears with both poverty (Bird, et al., 2011) and higher HIV/AIDS risks (Patel, et al., 2014). Combined with the recent publication of how PNs can be the country’s resource depleted “professional glue” between patients and high level medical care (Nsereko, et al., 2011), PNs themselves seem to be uniquely positioned to play a central role in formulating meaningful policy change at the national level, as both patient advocates and burgeoning international leaders of their profession.

US Policy Change

It would be an understatement to say that US health care policy has undergone dramatic changes in the last 12 months. Although the Affordable Care Act is in the midst of its first implementation phase, PNs practicing in the US must still devote themselves to advocating for specific policies that prevent patients from getting the mental health care they need. One notable policy change promulgated by the APNA (2012) centers on legally mandating adequate in-patient PN staffing to safely administer medications and monitor patients in these facilities. Over 1.8 million of the sickest and most vulnerable of mentally ill individuals rely on PNs to give all aspects of inpatient care, particularly in organizing conditions for healing, reengagement with recovery, and the safety of patients and staff. Ensuring adequate PN staffing in these facilities improves patient outcomes, but present policy and corresponding laws allow for dangerously thin staff levels at state run facilities. To PNs practicing in these 24-hour care settings, this policy changes may seem less global than the ones facing PNs in Uganda, but the consequences of failure are no less severe to target patient populations and the PNs who serve them.

Conclusion

Despite their stark differences, when it comes to mental health care, each country lacks a fully adequate response to many of its citizens’ manifest needs. In a certain peculiar light, it is particularly shocking that American PNs, surrounded by immense financial and scientific resources, still face so many barriers to caring for the mental health needs of many suffering citizens, some of which mirror the same problems experienced by Uganda’s PNs. The question, then, is not whether Uganda and the US need PNs; the question is how each responds to the mental health needs concerns of citizens from the unique perspectives of those who are on the front lines of care. Each country’s PNs therefore have lessons of their own to teach, so that each can be a student and each an instructor of meaningful change.

References

APNA Staffing Task Force (2012). APNA position statement: Staffing inpatient psychiatric units. Journal of the American Psychiatric Nurses Association, 18(1), 16-22. doi:10.1177/1078390311432133

Beronio, K., Po, R., Skopec, L., & Glied, S. (2013). Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. Retrieved from U.S. Department of Health and Human Services website: http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm

Bird, P., Omar, M., Doku, V., Lund, C., Nsereko, J. R., & Mwanza, J. (2011). Increasing the priority of mental health in Africa: findings from qualitative research in Ghana, South Africa, Uganda and Zambia. Health Policy and Planning, 26(5), 357-365. doi:10.1093/heapol/czq078

Department of Law & Public Safety (2013). New Jersey Division of Consumer Affairs - Board of Nursing. Retrieved from Office of the Attorney General website: http://www.njconsumeraffairs.gov/nursing/genifo.htm

Fung, Y. L., Chan, Z., & Chien, W. T. (2013). Role performance of psychiatric nurses in advanced practice: A systematic review of the literature [Abstract]. Journal of Psychiatric Mental Health Nursing. doi:10.1111/jpm.12128

Hall, J., D'Ardenne, P., Nsereko, J., Kasujja, R., Baillie, D., & Mpango, R. (2014). Mental health practitioners' reflections on psychological work in Uganda: Exploring perspectives from different professions. British Journal of Guidance & Counselling, 1-13. doi:10.1080/03069885.2014.886672

Hanrahan, N. P. (2012). Psychiatric nurse staffing in hospitals: Is it adequate? Journal of The American Psychiatric Nurses Association, 18(1), 27-29. doi:10.1177/1078390311431816

Kigozi, F., Ssebunnya, J., Kizza, D., Cooper, S., & Ndyanabangi, S. (2010). An overview of Uganda's mental health care system: results from an assessment using the World Health Organization's assessment instrument for mental health systems (WHO-AIMS). International Journal of Mental Health Systems, 4(1), 1-9. doi:10.1186/1752-4458-4-1

Leung, P., LaChapelle, A., Scinta, A., & Olvera, N. (2014). Factors contributing to depressive symptoms among Mexican Americans and Latinos. Social Work - A Journal of the National Association of Social Workers, 59(1), 42-51. doi:10.1093/sw/swt047

McLaughlin, K. A., Green, J. G., Alegria, M., Costello, E. J., Gruber, M. J., & Sampson, N. A. (2012). Food insecurity and mental disorders in a national sample of U.S. adolescents. Journal of American Academy Adolescent Psychiatry, 51(12), 1293-1303. doi:10.1016/j.jaac

Ministry of Education and Sports (n.d.). Butabika School of Psychiatric Nursing — Uganda BTVET - Business Technical Vocational Education and Training. Retrieved March 27, 2014, from http://www.btvet-uganda.org/training-provider/homepages/butabika-school-of-psychiatric-nursing

Ministry of Health – Republic of Uganda (n.d.). Ministry of Health – Republic of Uganda. Retrieved March 27, 2014, from http://health.go.ug/mohweb/

Nankumbi, J., Groves, S., Leontsini, E., Kyegombe, N., Coutinho, A., & Manabe, Y. (2011). The impact on nurses and nurse managers of introducing PEPFAR clinical services in urban government clinics in Uganda. BMC International Health & Human Rights, 11(1), 1-10. doi:10.1186/1472-698X-11-S1-S8

Nsereko, J. R., Kizza, D., Kigozi, F., Ssebunnya, J., Ndyanabangi, S., Flisher, A. J., & Cooper, S. (2011). Stakeholder's perceptions of help-seeking behaviour among people with mental health problems in Uganda. International Journal of Mental Health Systems, 5(5), 1-9. doi:10.1186/1752-4458-5-5

Patel, S., Schecter, M., Sewankambo, N., Atim, S., Kiwanuka, N., & Spittal, P. (2014). Lost in transition: HIV prevalence and correlates of infection among young people living in post-emergency phase transit camps in Gulu District, Northern Uganda. PLoS One,9(2), 1-10. doi:10.1371/journal.pone.0089786

Petersen, I., Ssebunnya, J., Bhana, A., & Baillie, K. (2011). Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda. International Journal of Mental Health Systems, 5(8), 1-12. doi:10.1186/1752-4458-5-8

Ssebunnya, J., Kigozi, F., & Ndyanabangi, S. (2012). Developing a National Mental Health Policy: A Case Study from Uganda. PLoS Medicine, 9(10). doi:10.1371/journal.pmed.1001319

Uganda Nurses and Midwives Council (n.d.). Uganda nurses and midwives council. Retrieved March 27, 2014, from http://www.unmc.ug/

World Health Organization (2011). Mental Health Atlas 2011. Retrieved from Department of Mental Health and Substance Abuse website: http://www.who.int/mental_health/evidence/atlas/profiles/uga_mh_profile.pdf

World Health Organization (2013, December). Mental health: A state of well-being. Retrieved March 27, 2014, from http://www.who.int/features/factfiles/mental_health/en/

Zauszniewski, A. J., Bekhet, A., & Haberlein, S. (2012). A decade of published evidence for psychiatric and mental health nursing interventions. The Online Journal of Issues in Nursing, 17(3). doi:10.3912/OJIN.Vol17No03HirshPsy01