Dearth of literature on barriers to provision of psychiatric nursing care in Nigeria : Findings from a literature review

The literature review was conducted to review barriers to provision of psychiatric nursing care in the world. The literature search highlighted a dearth of literature in Nigeria on barriers to provision of psychiatric nursing care, highlighting a gap in knowledge base that needs to be filled. The aim of publishing this literature review is to fill the gap in knowledge highlighted. The literature review was discussed under four headings namely: universal barriers, barriers in Nigeria, barriers in some middleincome economies and barriers in some high-income economies. The implications of discussing the barriers under various heading were also discussed.


INTRODUCTION
This article outlines the literature included in a study, conducted in Nigeria, which included the literature review that was conducted prior to the development of the research proposal and during data collection/data analysis process.The literature reviewed prior to data collection was used to develop the proposal for the study.It provided the researcher with baseline information to start the research process.This agrees with Burns and Grove (2011), who documented that literature review provides the researcher with knowledge on what is known and what is not yet known about the phenomenon.The literature review conducted prior to data collection also identified the dearth of literature on barriers to the provision of psychiatric nursing care in Nigeria.This is in line with the assertion of Burns and Grove (2011) that literature review allows for identification of gaps in knowledge base.
The literature reviewed during data analysis was used to confirm the discovered themes and subthemes as findings and to allow for discussion of findings.It also enhanced the researcher's objectivity in the interpretation of data.The literature review highlighted several barriers to provision of psychiatric nursing care which were grouped into five themes, namely: personal, relationship related, environmental, organisational and societal barriers to provision of psychiatric nursing care.Personal barriers were those barriers related to the individual's intrinsic capabilities that were perceived to hinder the individual from providing psychiatric nursing care.Relationship related barriers included the influence of relationship among the psychiatric nurses, between the psychiatric nurses and the patient, the psychiatricnurses and the patients' relatives, the psychiatric nurses and other members of the psychiatric team and between the psychiatric nurses and the management of the hospital on the provision of psychiatric nursing care.
Environmental barriers on the other hand, implied those physical structures that constitute barrier to provision of psychiatric nursing care.Public related barriers implied government activities, societal values and belief systems that influence the provision of psychiatric nursing care by the psychiatric nurses.Lastly, organisational barriers were those barriers related to human resources, policies, and other tools within the organisation that constitute a barrier to provision of psychiatric nursing care.
The dearth of literature on barriers to provision of psychiatric nursing care in Nigeria was identified.The literature review also revealed that personal, relationship related and physical environment related barriers were not reported in any of the Nigerian literature.This indeed highlighted gaps in knowledge that suggests absence of baseline data for conducting studies in psychiatric nursing.

METHODOLOGY
The following search engines were used to search for data: CINAHL, MEDLINE, Africa-wide information, Psych Info, Psych articles, Health source: Nursing/academic edition, eBook collection (EBSCOhost) and Google Scholar.Items from 2000 to date were used For the Google Scholar search.This was done to allow an extensive search of relatively recent articles.For the other databases, only items from 2012 to 2014 were used for searching literature from around the world.These data bases had a pull of articles that the researcher could not reviewed within the period of study, hence needed to narrow the search.The search was also restricted to 2012 to 1014 to access most recent articles.For the literature search from Nigeria, 2000 to date was used for all databases.This was done to ensure all relatively recent articles from Nigeria were accessed.The search terms used included: psychiatric nursing, mental health nursing, psychiatric, mental health, nursing, barriers, obstacles, constraints, hindrances, lived experience, resilience and psychiatric nurses.The researcher also searched for related articles in databases in which a particular article was accessed.ScienceDirect made suggestions for related articles each time the researcher accessed an article from it, and these were also accessed.Grey literatures were also searched.The inclusion criteria were as follows: articles that met the aim of the study, articles published in English, articles published between 2000 and 2014.Only articles that met the inclusion criteria were included in the literature review.The articles retrieved from the search were appraised for suitability, relevance, currency and trustworthiness.

Overview of barriers to provision of psychiatric nursing care
The literature reviewed, highlighted a number of personal-or individual-related barriers, organisational-or hospital management-related barriers, physical environment-related barriers, societal barriers and relationship-related barriers to the provision of psychiatric nursing care in hospital settings.The literature was discussed under three main headings, namely: barriers in low-income, middle-income and high-income economies as described by World Bank Group (2014).

Universal barriers to provision of mental health globally
The WHO (2001), reported that the absence of or inadequate mental health policy and legislation, poor hospital conditions, poor infrastructure, insufficient resources, human rights violations, inadequate treatment and care/high cost of treatment constitute barriers to provision of psychiatric nursing care.Other barriers identified by the WHO ( 2001) included lack of skills and training and lack of specialist and general health workers with psychiatric knowledge and skills.The WHO (2001) report referred to some of these as universal barriers to the provision of mental health care.They include lack of mental health services, poor quality of treatment and services, and access/equity-related barriers.Other barriers identified by the WHO ( 2001) included lack of skills and training, lack of specialist and general health workers with psychiatric knowledge and skills.Another important issue raised by the WHO (2001) was that approximately half of the existing legislation on mental health was formulated in the past ten years, while close to one-fifth dates back over four decades.The legislation on mental health in Nigeria, dates back to 1991 (WHO, 2001(WHO, , 2011)).The implication of this is that psychiatric nurses in the hospitals, including the research setting are faced with the challenge of working within an old legal framework that may not allow them to provide optimal psychiatric care to psychiatric patients.

Barriers to provision of psychiatric nursing care in Nigeria, a low-middle-income economy
Literature reviewed identified government-and organisational-related barriers to provision of psychiatric nursing care in Nigeria.Jack-Ide et al. (2012,2013) reported the lack of political power and the absence of a nursing voice in the Ministry of Health, depriving the psychiatric nurses of the opportunity to be heard and/or receive attention at this level.Stigma within the hospital setting, lack of in-service training, system failure, and lack of access to treatment due to high costs were also identified as organisational-related barriers to provision of psychiatric nursing care in Nigeria (Jack-Ide et al., 2013).Similarly, Klecha et al. (2004) in a report of the activities of a foundation in Nigeria, remarked that governmentand organisational-related issues constitute barriers to provision of psychiatric nursing care to patients.They remarked that scarcity of resources such as equipment and manpower and placement of low priority on psychiatric services by management of hospitals and the government also constitute barriers to provision of psychiatric nursing care.
The WHO (2011), reported that the majority of primary health care nurses in Nigeria have not received any official in-service training on mental health within the last five years.The lack of current knowledge on psychiatric nursing care could affect the care provided by the psychiatric nurses in that country.Furthermore, statistics have shown that there are just 0.19 nurses working in psychiatric hospitals in Nigeria per 100 000 members of the population (WHO, 2011).This indicates gross inadequacy of manpower, which has been reported in literature to constitute a barrier to provision of psychiatric nursing care.Additional government-and organisationalrelated barriers to provision of psychiatric nursing care highlighted by the World Health Organisation (WHO) and the Nigerian Ministry of Health reports, include the nonavailability of essential drugs, lack of an office for mental health issues in the Federal Ministry of Health and poor budgetary allocation to psychiatric practice by government (WHO and MoHN, 2006).
It can be concluded that only government-and organisational-related barriers to provision of psychiatric nursing care have been reported in Nigerian literature.This is probably due to the adoption of a narrow scope by the studies, or other reasons beyond speculation.For instance, the study conducted by Jack-Ide et al. ( 2013) used Townsend's mental health template to guide their discussion.This construct comprises only structural and resources constructs.The absence of literature on the other barriers reveals a gap in knowledge, which this study will contribute towards filling.

Barriers to provision of psychiatric nursing care in middle-income economies
Manpower-related barriers have been identified in middle-income economies such as Iran and South Africa.For instance, in 2007 the WHO and International Council of Nurses (ICN) highlighted that the greatest barrier to provision of psychiatric nursing care in the low-and middle-income economies is severe shortage of manpower.They stated that there are fewer psychiatric nurses per capita in low-income economies and middleincome economies than in high-income economies.Lack of adequate opportunities for acquiring knowledge and skills in psychiatric nursing during regular nursing education and post-regular nursing education was reported to exacerbate the problem (WHO and ICN, 2007).Other societal and organisational-related barriers to provision of psychiatric nursing care in low-and middleincome economies highlighted in literature include neglect of the psychiatric unit by hospital management, neglect by the public and the healthcare system, politics and rules of organisation (McDaid et al., 2008;Ngako et al., 2012;Zarea et al., 2012;2013).Other authors reveal a number of organisational barriers to provision of psychiatric nursing care, including lack of, inadequate and poor distribution and appropriateness of resources like trained psychiatric nurses, ward facilities, sociocultural issues and lack of time to plan and provide care, which has been reported to be more critical in psychiatric nursing than other fields of nursing (Knapp, et al, 2006;Schierenbeck, et al. 2013;Zarea et al., 2012Zarea et al., , 2013)).Relationship-related barriers to provision of psychiatric nursing care were also highlighted in the literature review from middle-income countries such as South Africa and Iran.These include patients' disrespectful and uncooperative attitudes towards psychiatric nurses, lack of mentoring/supervision by superiors, lack of emotional and psychological support from management and patients' relatives and unsupportive behaviours of psychiatrists, security personnel and patients' relatives.Psychiatric nurses were reported to be of the opinion that these barriers result in demotivation, emotional/physical distress and suppression (Tema et al., 2011;Ngako et al., 2012).
Several personal-related barriers to provision of psychiatric care have been highlighted in literature from Iran and South Africa.For instance, Zarea et al. (2012) reported that lack of sufficient skills and knowledge, uncertainty of one's role; burn-out and safety issues constitute barriers.Ngako et al. (2012), revealed that security issues like fear of injury by patients, fear related to unpredictable behaviour of patients and demotivation constitute barriers to provision of psychiatric nursing care.Similarly, in a study conducted by Tema et al. (2011) it was revealed that law and legal issues associated with potential harm to patients were viewed by psychiatric nurses as a barrier to provision of psychiatric care to psychiatric patients.
The literature review on barriers to provision of psychiatric nursing care in middle-income economies revealed government and organisational barriers, relationship-related barriers and personal barriers.Environment-related barriers to provision of psychiatric nursing care are reported in the literature from low and middle-income countries.

Barriers to provision of psychiatric nursing care in high-income economies
Literature review revealed environmental factors that constitute barriers to provision of psychiatric nursing care in high-income economies.In four different studies conducted in Turkey and Australia, lack of a family-centred environment, poor/unfavourable working conditions and a noisy and busy environment were reported to constitute barriers to provision of psychiatric nursing care (Eren, 2014;Innes et al., 2014;McAllister and Moyle, 2008;Smith and Khanlou, 2013).Other environment-related barriers to provision of psychiatric nursing care highlighted in the literature are limitations in the work setting and hazards in the physical environment (Brennan et al., 2006;Innes et al., 2014;Weiland et al., 2011;Yadav and Fealy, 2012).Chevalier et al. (2006) and Rose and Glass (2006) argued that an unsuitable physical environment exposes psychiatric nurses to physical, emotional and psychological harm which jeopardises psychiatric nursing care provision.
Several organisational-related barriers that affect provision of psychiatric care by psychiatric nurses have been highlighted in the literature.For instance, in three different studies conducted in Australia structural and policy issues in the workplace were reported to play a significant role in the burn-out which psychiatric nurses experience in the hospital setting (Fisher, 2014;Hercelinskyj et al., 2014).This barrier was reported to produce role conflict and stress, leading to role strain (Fisher, 2014;Hercelinskyj et al., 2012), which obviously incapacitates the psychiatric nurses' productivity, hence constituting a barrier to provision of care.
Other organisational barriers which psychiatric nurses face while providing psychiatric care to psychiatric patients in hospital settings as identified in literature were: long shifts, too much paperwork and administrative duties, involvement in a variety of duties within limited time and huge workload (Mesidor et al., 2011;Patton, 2013;Eren, 2014;Happell, 2014;Wong, 2014;Brennan et al., 2006;Innes et al., 2014).The endless lists of organisationalrelated barriers to provision of psychiatric care in hospital settings include: leadership styles that are problematic, bureaucratic processes and complex management systems, and the predominant use of the medical model and relegation of the role of the psychiatric nurse to the background by management (Mesidor et al., 2011;Fisher, 2014;Stein, 2014;Chevalier et al., 2006;McAllister and Moyle, 2008;Yadav and Fealy, 2012).
Literature reviewed also highlighted several personal barriers to provision of psychiatric nursing care in highincome economies.For instance, Brennan et al., (2006) revealed that lack of knowledge of their role within the health team and in the attainment of organisational goals and lack of autonomy constitute barriers to provision of psychiatric nursing care.Other personal barriers to provision of psychiatric care are as follows: lack of appropriate and specific training and education, inability to use acquired skills due to time constraints and huge workload, and allocation to inferior roles within the psychiatric health team (Mathers, 2012;Wong, 2014;McAllister and Moyle, 2008).Other personal barriers to provision of psychiatric nursing care highlighted in literature in high-income economies include: indifferent attitudes of some psychiatric nurses towards provision of care, lack of interest in provision of psychiatric care among some psychiatric nurses, low morale and low selfesteem/confidence, and frustration from managers over perceived under-performance of their subordinates Gimba and Sinegugu 19 (Wong, 2014;Brennan et al., 2006;Chevalier et al., 2006;Jelinek et al., 2011).Barriers to provision of psychiatric care that have their origin in society have been reported in the literature, and these include isolation from the public and lack of knowledge or misconceptions about what psychiatric nursing is by the public and other health personnel (Chevalier et al., 2006;Yadav and Fealy, 2012;Jackson and Morrissete, 2014).According to Chevalier et al. (2006) the greatest barrier to provision of psychiatric care is lack of knowledge by the public of the existence of advanced practice roles of psychiatric nurses and lack of understanding of the role of psychiatric nurses by other health professionals.Relationship-related barriers to provision of psychiatric care have been identified in the literature, and include lack or poor strengthening of the utilisation of acquired skills and competences by managers, lack of training and education support from psychiatric nursing managers, and unhealthy attitudes of nurse managers toward issues of autonomy and professionalism (Greenall, 2006;Mathers, 2014;Smith and Khanlou, 2013).Other relationship-related barriers which psychiatric nurses face while providing psychiatric care which are highlighted in the literature include difficulty in obtaining patients' vital information from relatives and overbearing attitudes (like opposition to treatment provision) of the patients' relatives (Wong, 2014;Innes et al., 2014;Jackson and Morrissette, 2014).
Additional relationship-related barriers to provision of psychiatric care revealed in the literature include poor supportive peer relationships among psychiatric nurses, oppression from peers, uncooperative management who do not provide support and inadequate morale-boosting by management (Fisher, 2014;McAllister and Moyle, 2008).Barriers to the provision of psychiatric nursing care in high-income countries seem to be very comprehensive, exhaustive and revealing.This may be due to the volume of published articles in circulation and/or the quality of the research process which the researchers adopted.This is in contrast to barriers to provision of psychiatric nursing care that were revealed from literature accessed and reviewed in low-income and middle-income countries including Nigeria.This may be due to the low number of publications on barriers to provision of psychiatric nursing care in circulation, lack of interest or resources in carrying out research, of research conducted by researchers in psychiatric nursing, or even poor documentation of findings of research.This therefore, reinforces the need for psychiatric nurse researchers from middle-income countries and the African continent in particular to resolve issues bedevilling availability of literature on barriers to provision of psychiatric care.

CONCLUSION
The literature reviewed gave an outline of the barriers psychiatric nurses face while providing psychiatric care at different levels.This included: personal, relationship, environmental, organisational and public level.Another revelation is that some barriers are universal which included shortage of manpower (the most significant), lack of or inadequate resources such as equipment, inadequate or limited policy, inadequate training and trained psychiatric nurses, poor welfare from management, unhealthy relationships among the psychiatric health team, and poor educational and training opportunities.The dearth of literature on barriers to provision of psychiatric nursing care in Nigeria was highlighted.