Are Nurses Working in Mental Health in a Time of Changing Approaches More Exposed to Stress than other Professionals? Job Satisfaction and Perception of Respect for the Rights of Users in Seven Different Countries Worldwide

1. INTRODUCTION

The policies that promote psychiatric care from the centrality of hospital care to community care involve modifications of the roles of health professionals [1-3]. Among all the figures, among those having a higher impact by the transformation policies are nurses, whose role is linked to consolidated skills in a hospital care setting, but they find uncertain boundaries and, in many respects, to be defined in a community care system [4]. All this can increase the risk of burnout or just job dissatisfaction even in situations in which the transformation is started to be barely mentioned in practice, but the principles that inspire it are novelty shared [5]. Another element that accentuated the working risk conditions for nurses was the COVID-19 pandemic.

In countries in which the change in the mental health system seems more consolidated, such as Italy, a country considered at the forefront in the implementation of community assistance policies in mental health, the situation of the nurse in the context of community assistance was no longer at risk than other professionals [6, 7]. However, even in this country and in other countries with developed community care networks, some recent phenomena have changed the situation of the nurse in the mental health system. Firstly, the economic crisis has reduced resources for community care and, secondly, the pandemic crisis has highlighted a greater risk of stress in nurses compared to other health professionals, perhaps because they are more exposed to risk [8-10].

A recent line of research by our group has supported the hypothesis that the perception of respect for the rights of people with psychosocial disabilities by health workers in mental health centers is an essential element of the organizational well-being of these structures, i.e., the greater the perception that user rights are respected, the greater the well-being and satisfaction of workers [11-13].

Given our premises on the specific role of the nurse in mental health services in this historical moment of transition (and after the strong stressing COVID era), it may be interesting to investigate whether there is a specificity of this figure in the perception of organizational well-being and the related perception of the user's rights.

Our work was inspired by the United Nations Convention on the Rights of Persons with Disabilities (CRPD) which highlighted the relevance of the respect of rights and the active participation of people with disabilities in decisions affecting their lives, including around health treatments [14]. This issue is especially critical in the context of psychosocial disabilities, where discrimination and human rights violations are frequent [15]. In fact, although mental health conditions account for one-third of the global burden of disability [16], more than 70% of those having needs do not have access to quality services [17]. Prior to the Covid-19 pandemic, spending on mental health was less than 2 dollars per person per year and even less in low-income countries [18]. However, this expenditure has further decreased due to the pandemic [19].

In response to these challenges, the World Health Organization's QualityRights program seeks to incorporate the principles of the CRPD in the field of psychosocial disability [20, 21].

The condition of the nurse in mental health care is, therefore, that of a critical professional figure in a critical care area. Our research primarily aims to evaluate how the organizational well-being of nurses in mental health services in the selected countries affects and is affected by the perception of respect for their rights and those of the users. Furthermore, it seeks to describe the differences and similarities in the experiences of nurses in these countries. Through a descriptive quantitative approach, these dynamics will be explored, allowing a detailed and comparative analysis of the data collected in different settings and facilitating the identification of key patterns and differences between the studied regions.

2. METHODS

3. RESULTS

Table 1 illustrates the characteristics of the sample of nurses recruited for the study, and the Italian sample is clearly more represented in the last two categories by age, i.e., those over 49 years of age (75% in Italy versus 19.9% in the rest of the countries, chi-square 161, 445, p<0.0001); while in Argentina women are more frequent (85% vs 60.2% in the rest of the nations, chi-square 26, 442, p<0.0001). The primary exposure was the professional role, with comparisons made between nurses and other health professionals regarding job satisfaction, organizational well-being, and respect for users' rights. Geographic location (Mediterranean vs. Latin American countries) was also considered, as it potentially modifies the effects of professional role on these outcomes.

The primary objective of this study was to evaluate the differences in job satisfaction, organizational well-being, and perception of respect for user rights among mental health nurses compared to other health professionals across diverse geographic contexts.

Table 2 shows the comparison between nurses and other health professionals in the responses to the questionnaire. In none of the responses was a statistically significant difference in answers between nurses and other health professionals, even if on item 3 (How much are you satisfied with the organizational aspect of your work/how is your work organized?) the difference, in the sense of lower satisfaction in nurses, is at the limit of statistical significance (3.73±1.43 in nurses versus 3.91±1.42 in other professionals, Z=1.852, p=0.0641). However, when comparing between individual countries (Table 3), divergent scores at responses with higher score among nurses in Macedonia in items 1 “How satisfied are you with your job?” (chi square, 5 df, = 41.391, p<0.0001); Item 2 “How satisfied do you think the users of your service department are?” (chi square, 5 df, = 33.216, p<0.0001); Item 3 “How satisfied are you with the organizational aspect of your work/how your work is organised?” (chi square, 5 df, = 42.604, p<0.0001); Item 4 “How much do you think the human rights of the users of your service/department are respected?” (chi square, 5 df, = 35.903, p<0.0001); Item 5 “How much do you believe that the human rights of your staff are respected?” (chi square, 5 df, = 48.8228, p<0.0001), and lower in Item 6 (in which, however, the value is reversed, i.e. lower scores correspond to better satisfaction) “How do you rate the current state of mental health care in your service/department, with reference to resources?” (chi square, 5 df, = 36.771, p<0.0001); in Tunisia, in reverse, some items showed low scores in nurses: Item 1 “How satisfied are you with your job?” (chi square, 5 df, = 14.753, p=0.011); Item 3 - “How satisfied are you with the organizational aspect of your job/how your job is organized?” (chi square, 5 df, = 11.959, p=0.035), but with Item 4 showing a higher score in nurses “How much do you think the human rights of the users of your service/department are respected?” (chi square, 5 df, = 12.141, p=0.033).

4. DISCUSSION

Our study has highlighted, in partial contrast with the initial hypothesis, that, considering all the countries analyzed, no differences emerge between the responses of nurses and those of other healthcare professionals working in mental health on job satisfaction, perception that users are satisfied by the care they receive, satisfaction with the organizational aspects at work, perception that the human rights of the users of your service/ward are respected, perception that the human rights of the staff where you work are respected, satisfaction with the current state of care in mental health in your service/ward, with reference to availability resources?

In this work, the comparisons between nations were made by comparing the differences between nurses and other professionals within the nations and not as absolute values of the nurses' responses in each specific nation, on the assumption that these values in nurses alone are extremely influenced by contingent variables because a direct comparison is reasonably discussed, while a specific national difference between nurses and other professionals would have been more useful for verifying the starting hypotheses. From this point of view, when we evaluate what happens in individual nations, we find that in North Macedonia, nurses respond with scores that show greater satisfaction than other professionals in all the items considered, while in Tunisia, nurses express lower scores in the items relating to job satisfaction, satisfaction about organization at work but higher considering respect for user rights.

How to explain these results?

First, both North Macedonia and Tunisia have had to face serious emergencies in the organization of health services and mental health services. In North Macedonia, tubular spending on health has declined in recent years, it is among the lowest in Southeast Europe [22] and “There is strong reliance on out-of-pocket payments which represent 40.4% of total health spending, one of the highest shares in South-Eastern Europe” [22]. The general health emergency has affected mental health to an even greater extent, which has suffered mainly the impact of the pandemic [23]. This is why the renewal plans have tried to involve this area, too. After fierce protests from healthcare workers in the years preceding 2022 (in which these data were collected), the government promoted a general reform involving general practitioners in the provision of specialist care. Following the collection of our data, the first corrective interventions were conducted by the government with the support of the WHO. Some recent reports have noted several “remaining challenges” [24], such as insufficient number of health professionals, low number of medications covered by health insurance, transportation barriers for accessing health services in rural areas, inadequate gender norms and waiting time in obtaining appointments [24]. In this context we cannot say that the nurses were satisfied, but the most dissatisfied of all were the doctors who, also on an economic level, had salaries that were proportionately lower than in neighboring European countries.

Tunisia's health situation appears equally critical. The country is experiencing a serious economic crisis that has been worsened by drought and impact of COVID-19 pandemic [25]. It has drastic repercussions on the salaries of staff employed in the public healthcare system and on the availability of drugs and healthcare products [26]. The fact that there are well-structured public universities plays a paradoxically negative role because well-trained, multilingual doctors, psychologists, and nurses find it easy to emigrate, especially to the rich Gulf countries and French-speaking countries such as Canada, Belgium, France and Switzerland. The result is a drastic shortage of personnel, which has a greater impact on the most often penalized healthcare areas, such as mental health [20, 26]. The fact that nurses present higher levels of job dissatisfaction compared to other health professionals in a context in which everyone is dissatisfied with their salaries, and nurses are the most dissatisfied of all because, in terms of the economic unsustainability of daily life, they are the ones who have the lowest net salaries (around 400 Euros / Month) compared to doctors, psychologists, and administrative staff members. The discrepancy, already highlighted in Tunisia concerning all professionals, in the correlation between job satisfaction and perception of respect for users' rights should be interpreted in the light of the above mentioned situation [11]. Indeed, in this context, the perception of non-respect for one's rights and the consequent anger could lead to not paying attention to the rights of others [11].

While not fully confirming the starting hypotheses, however, some of the starting hypotheses are confirmed by our results, that is, due to their position of close contact with users, strong proximity to them, and the strong impact of the profession in terms of potential stress, nurses are the most fragile segment of the healthcare system in the event of a crisis. In the case of North Macedonia and Tunisia, however, the pandemic may have been a co-factor of the critical situation but not the only element, while the crisis of the transformation of care towards a community-centered system does not seem to have played a relevant role. The real crisis seems to be caused in the two nations by strictly economic issues.

Another relevant element is that in two nations with a critical situation of mental health care, which causes greater dissatisfaction in overall professionals, nurses respond in the opposite way in relation to the specific context, just as the perception of users' rights is opposite. Specific elements linked to culture and specific working conditions probably produce the differences while interacting with general and universally applicable values linked to concepts relating to human rights.

In general, the already demonstrated relationship between job satisfaction and perception of respect for rights [27, 28] is confirmed, although there are some cases of extreme job dissatisfaction, as in Tunisia, in which we found opposite results.

Our study offers valuable insights into the experiences and perceptions of mental health professionals, but several limitations should be acknowledged. The self-report nature of the questionnaire could introduce response biases, as participants may respond in socially acceptable ways. The voluntary participation method may have led to a non-representative sample, skewing results due to motivated individuals being more likely to participate. Furthermore, although the sample size of 900 participants appears adequate for the study, ensuring good representativeness of national groups and backgrounds, however, due to the very multicenter nature of the study, differences in sampling methods between countries could affect the comparability of the data and should be taken into account when analysing. This fact should be considered equally with the possibility of evaluating data from clinical settings that appear in some cases to be difficult to reach and investigate.

The response rate could not be determined, affecting the representativeness of the data. Additionally, the dual administration modes (online and paper) might have influenced responses, impacting data consistency. Moreover, country-specific factors and the predominance of nurses and psychologists in the sample could further affect the findings.

CONCLUSION

The study seems to confirm that nurses represent the category most sensitive to critical situations that can impact the quality of care provided and this influences both job satisfaction and the perception of respect for user’s rights. However, given the situation in the nations examined, the most critical conditions highlighted concern general economic factors and not, as expected, the transition from hospital care to community care.

REFERENCES