The considerable increase in the number of patients living with mental illness is becoming increasingly difficult to ignore. In 2017, the United States highlighted mental illness and cited 46.6 million people or nearly one in five adults who have a mental illness (Substance Abuse and Mental Health Services Administration, 2018). Meanwhile, the World Health Organization estimates that 11,000 persons registered for mental health services in Brunei in 2012, with 137 readmissions in 2017, 160 readmissions in 2018, and 141 readmissions in 2019 (WHO, n.d.). This prevalence of mental illness has resulted in the development of mental health services providing care, treatment and the preservation of human rights of people with a mental disorder. However, readmission is inevitable as a consequence of the expansion of psychiatric services and has become substantial, causing mental health services to face significant challenges. Previous studies indicate high readmission rates in the psychiatric setting and indicate relapse symptoms (Vasudeva et al., 2009; Vigod et al., 2015; Chi et al., 2016).
From the literature review, the patient and healthcare professional differ in their understanding of reasons for readmission. Patient views of their readmission were more focused on the non-compliance of medication as the main factors for readmission (Mgutshini, 2010). However, according to Glette et al. (2019), healthcare professionals perceived readmission due to patients being prematurely discharged from the hospital. In addition, one study found that patient readmission was avoidable, as long as the patient is included in the procedure, such as better symptom management or greater clarity in the discharge instruction (Howard Anderson et al., 2016). Despite patient views of healthcare from the literature, readmission from the nurse perspective is under-researched.
Prior studies have also identified numerous factors that have contributed to readmission for psychiatric patients. The most notable reason mentioned was lack of insight into the illness (Nxasana & Thupayagale-Tshweneagae, 2014), negative attitudes of the patient towards medication and a lack of support from the family (Dlamini & Shongwe, 2019). In a qualitative study by Cleary et al. (2013), nurses considered that recovery involved maintaining well-being through a concept of holism, which includes relationships, psychological problems, psychosocial and life skills. The failure to maintain recovery thus causes a recurring health problem. Readmission from the nursing perspective was typically attributed to a family belief system, a lack of social support, patients’ negative attitudes, and organisational health factors. Glette et al. (2019) strongly agree that healthcare administration factors caused patient readmission.
Meanwhile, Nxasana and Thupayagale-Tshweneagae (2014) highlighted no studies of nurses’ perceptions regarding psychiatric patient readmission. Therefore, readmission from the perspective of the nurse is an emerging yet unexplored area. Cleary et al. (2013) stated that nurses have a central role in patient recovery and supporting, hoping, learning, and providing positive nursing experiences that constitute humanistic interpersonal nursing. This understanding of roles can lead to initiatives that reflect the quality of patient care and reduce readmission.
Methods
Study Design
A qualitative descriptive study design was undertaken as it was the most appropriate in addressing the research questions. It allows the voices of nurses in Brunei to be heard, thereby creating a real opportunity to explore perceived reasons for psychiatric readmission in Brunei Darussalam.
Research Participants
The study was conducted in a primary psychiatric department in Brunei Darussalam. The participants were selected using a purposive sampling technique from nurses caring for patients in Brunei’s leading psychiatric service. The participants were approached by a department nurse manager who acted as a gatekeeper. Thirty nurses attended the briefings, and twenty-four nurses agreed to participate. They are between 28 and 52 years of age, with work experience in the psychiatric department varying from 3 to 20 years. The participant inclusion criteria include more than one year of working experience in the psychiatric department; thus, nurses with less than a year of working experience will be excluded.
Data Collection
This study was conducted in Brunei Darussalam between October 2020 and November 2020. The research team conducted a semi-structured interview using Focus Group Discussion (FGD). The following open-ended questions were presented in Malay and English: What is your perspective on factors causing patient readmission? What approaches can you suggest to overcome these factors? In what way will the patients have an impact on their experience of readmission? What is the effect of patient readmission on the nurse? Furthermore, how can the nurse support in helping to minimise patient readmission? All five FGD took place in a private meeting room within the department itself. The interviews, which lasted between 57 and 88 minutes, were audio recorded.
Data Analysis
All interviews were transcribed verbatim and analysed using six phases of the thematic process described by (Braun & Clarke, 2021). The first phase involved the research team reading and re-reading to become familiar with its content. In contrast, the second phase entailed coding the transcripts and collating all relevant data extracts for further stages of analysis. The third phase prompted the research team to examine the codes and collected data to establish meaningful broader patterns of potential themes. Phase four involved comparing the themes to the transcripts to ensure they presented a credible story about the data and answered the research question. The fifth phase involved doing a detailed analysis of each theme and defining its scope and focus. Finally, in phase six, the research team combined the analytic narrative and data extracts and contextualised the results in light of existing literature. It is critical to highlight that all phases were followed recursively, whereby we moved back and forth between phases. These phases were viewed as a roadmap for analysis, facilitating a complete and in-depth engagement with the data analysis. English words or phrases were used when translating from Malay to English since the source words have an English translation. However, there were no complicated words or phrases to translate or interpret.
Ethical Consideration
Since the study involves human participants, ethical clearance was obtained from both Faculty and Ministry of Health Research Ethics Committee (Reference: UBD/PAP RSBIHSREC/2020/62). Participants did not receive any monetary or other direct benefits for participating in the study.
Trustworthiness
Trustworthiness was described for the main qualitative content analysis phases, from data collection to reporting results (Elo et al., 2014). The four aspects of qualitative research’s trustworthiness are credibility, dependability, conformability, and transferability (Polit & Beck, 2018). All of these aspects have been established in this study. All interviews started with warm-up questions about their perception of factors causing readmission of the patient. This set of questions ensured that the participants shared a common understanding of the major causes of readmission. In addition, all the audio recordings were transcribed verbatim to retain the study’s conclusion’s quality of data analysis and objectivity.
Meanwhile, quotes from the participants were presented in the findings for conformability. For credibility, the analysis process was finalised in collaboration with all the researchers. This action is to verify coherency between themes and data (Graneheim & Lundman, 2004). The data was saturated during the fourth FGD, but to ensure that no more information emerged, one more FGD was carried out. The participants’ age range and level of experience were broad, contributing to the findings’ transferability.
Results
The analysis revealed three main themes and several subthemes which arose from the nurses’ reflections and working experiences in the psychiatric department.
Theme 1: The significant role of family
Nurses perceived that the reasons for psychiatric patient readmission were the family’s role as the patient’s primary carer. The nurses portrayed the patients’ families as the key personnel responsible for monitoring medication adherence to prevent readmission. The interrelationship between family as carers and managing patient medication was the primary finding cited by most nurses during the interviews:
I consider that family support is significant. If we think about it, the patient is unwell. If there is no such support, this can potentially lead to readmission. There are no people to monitor patient compliance. Almost all admitted patients will rely on the medication to get better? So medication compliance is critical. If we solely trust the patient to monitor their medication, I honestly think it will not be good enough. Hence, family support is essential. (Nurse 4, FGD4)
The family was perceived as the primary carer with at least one family member needed to focus on patient care. Nurses felt that due to the patient’s mental and physical capabilities being affected by psychiatric illness and the possible side-effects of medication, it was vital for the family to “step up” to patient care. Without family support, a patient can become fragile and vulnerable leading to further deterioration in their condition:
Mental health illness affects the patient thoughts process—both cognition and memory capabilities. The medication affects their memory of their thoughts, so their daily routine is somewhat affected. (Nurse 2, FGD1)
Most nurses, when interviewed, reflected on the impact of the current COVID-19 pandemic, whereby healthcare services and delivery faced challenges and interruptions worldwide. Brunei Darussalam’s healthcare system is no exception. Psychiatric services were restricted, and nurses identified families as having an essential role in updating the patient’s condition to the relevant services to prevent patient relapse. Nurses expected the family to have a significant role and duty in preventing the readmission of a patient. Furthermore, the family’s responsibility should not just focus on the patient’s medication; rather, it should encompass the multiple functions needed to ensure that patients do not relapse, which would necessitate readmission:
During the COVID pandemic, we are facing problems. We have to reschedule patients’ appointments for three months. Whenever we make the phone call to patients, trying to get updates and progress, the family would tell us that the patient is stable and experiencing ‘no problems’. We would then repeat the medication prescription for another three months. However, in reality, patients are not stable. Hence, the feedback from the family was not the same as the patient’s condition. This is why there were many relapses and recurrent admissions. (Nurse 4, FGD2)
However, from the interviews conducted, nurses perceived that responsibility for readmission rested with family members. The nurses verbalised that patient wellness was in the family’s hands to ensure patients did not relapse from their illness despite delivering the care and treatment prescribed. The possible family burden was discussed. Nurses foresee that the family have to do most of the physical and mental caring for the patient. As a consequence of being mentally unstable, patients were unable to look after themselves. Thus the family were expected to step in:
It is a double-edged sword; you know what I mean. If you are a family member, you have to think about it. Do I prefer to have this kind of caregiver burden? In addition, if the patient relapses, you have to weigh which approach you prefer? I think the family would like it if the patient did not fall ill, right? (Nurse 2, FGD1)
Furthermore, several nurses put forward another reason for the patient being readmitted, namely, medication non-compliance. Medication regime is vital for patients since the medicine is prescribed daily. Therefore, medication should not be missed or stopped without consultation with the doctor. Several nurses reflected on the causes of medication non-compliance leading to patient readmission:
Because of the stigma attached to mental health issues, some patients may start contemplating following the strict medicine regime. This is particularly true if the patient is furthering studies or seeking a new job. They may not want others to know that they are on mental health medication. In the end, they do not take medicine. (Nurse 2, FGD1 and Nurse 2, FGD3)
Theme 2: The value of psychoeducation
When asked about the support role of nurses to minimise psychiatric readmission, the majority of the nurses highlighted the importance of psychoeducation for the patient and their family to prevent readmission. Psychoeducation helps to increase patient insight and cultivates patient knowledge about their illness and treatment. It also enables a person with the knowledge needed to improve or maintain a patient’s condition:
I guess it is not always easy for the patient family to understand what mental health is. We must educate them on what is happening in the brain of a person having a mental illness. If a person understands the nature of the mental illness, what actually happened, why people get this illness and the causes of mental illness, this can make them more aware and improve family support (Nurse 4, FGD4)
The provision of psychoeducation for patients and families is vital to empower them through increased knowledge and understanding of the mental health condition:
I want to strengthen the nurse’s psychoeducation. We usually give psychoeducation to the family, particularly on the importance of medication. Unfortunately, some of them are still in denial. They may not feel that the patient needed any more medicine. Hence, they stop the medication. This patient will be soon readmitted. Therefore psychoeducation is essential for them. (Nurse 3, FGD5)
Psychoeducation, however, has its limitations; mental illness is often considered taboo and is linked to cultural beliefs. For example, some families believe that mentally ill patients are possessed in Brunei Darussalam because of black magic or similar phenomena. Such cultural beliefs make it difficult for some to believe that mental disorders do exist. Thus, psychoeducation in the context of such beliefs may have a low impact and may therefore be ineffective:
It is part of our culture to believe things like black magic or being possessed. For some, such a factor is difficult to accept. Some parents, for example, believed that mental health issues were related to being disturbed by black magic after entering the jungle. It is most likely that the parents may have a more challenging time accepting that their child is sick. (Nurse 2, FGD1)
Despite these cultural beliefs, nurses still have a role to support the patient’s recovery and help them understand their mental illness. The challenge to provide optimal treatment is, therefore, a very real one. To prevent readmission, nurses endeavour to understand this dynamic and the various treatments, such as cultural, spiritual and psychiatric treatments. Some of the nurses perceived a need to strike a balance between different forms of treatment:
When it comes to caring for patients with mental health issues, we also need to consider the dimension of religious and spiritual caring. We try to relate what spiritual care is. At least our patient is not misled from the fundamental objective. Sometimes, they did not know that spiritual care could help them. (Nurse 4, FGD2)
The importance of psychiatric community services in minimising patient readmission was mentioned several times during the study. The role of community nurses was seen as significant in delivering health care and aiding patient recovery. Psychiatric community services played an essential role in maintaining patient recovery. The psychiatric community’s involvement and directness were the leading factors preventing the patient from being re-hospitalised. Participant opinions reflected this:
I think community services are vital in the prevention of readmission. They can provide treatment services or injections at home for patients and their families who have a problem going to the hospital. Furthermore, community services can deliver medication to the patient. (Nurse 4, FGD5)
As the Psychiatric community is vital, improvement in services is necessary to ensure its effectiveness. Strengthening existing community services and expanding the workforce to deliver better services was suggested as a means of reducing readmission:
The community services need to strengthen their workforce: more community nurses should work in the service as limited staff can negatively impact the quality of healthcare services. Community nurses have limited time giving psychoeducation to patients and families as the nurses have other roles in delivering in the community healthcare services, such as providing depot injection. (Nurse 4, FGD4)
Theme 3: Addressing the needs of patients
In addressing the needs of patients, the participants reflected on the impact of readmission, which could be a positive or negative experience. The nurses reported that the patient could have a difficult experience while being readmitted to the ward, as the ward’s rules and regulations need to be followed:
This would be stressful for the patient for a more extended hospitalisation as they may feel constrained or ‘trapped’. For example, patients who smoke cigarettes may find it stressful since the hospital is a no-smoking zone. This stress can make them angry, which can further disturb staff working. (Nurse 5, FGD4)
Another participant reflected on how the hospital rules and regulations may limit the daily activities of patients:
There is scheduled meals time, watching TV, bedtime and many others. However, because of the rules, they may not be able to follow such rules and regulations. This can be upsetting for some patients. (Nurse 2, FGD4 and Nurse 2, FGD5)
Secondly, the impact of readmission on the nurse was considered. Various responses related to the participant’s emotional response in caring for a readmitted mentally ill patient. One participant shared their potential fear but fully understood the nature of their work and the patient’s condition:
It could be quite concerning if we learned about patient history, especially one with a history of aggression. This is particularly true for staff that have previously been assaulted, punched, slapped or traumatised by the patient. (Nurse 1, FGD4)
This was emphasised by another participant who believed that peer support was central in preventing traumatic incidents:
Usually, after a traumatic incident, staff will have a debriefing session where they shared and expressed their feelings. In a readmitted patient with a history of assaulting staff, we will ensure that the same staff will not treat the patient. (Nurse 1, FGD4)
The participants were able to develop the right mindset to ensure they acted professionally. However, looking after the patient who had repeatedly been admitted was deemed to be stressful:
We are doing the job as professional nurses. We have to accept that, for any readmission, we have a job to do. It can be stressful nevertheless, mainly if the patient is reluctant to improve their health. (Nurse 3, FGD5)
Discussion
This study’s primary concern was highlighting participant nurses’ views on the reasons for patients’ readmission in a mental health setting. Patients with mental health problems were impacted in many ways during their daily lives. The consensus was that there should be a pivotal person to help maintain the health of the patient. The nurses acknowledged that the family should play a central role in the supervision of patient medication. It was evident that the family’s ability to attend to their “claimed” roles significantly impacted the patient to prevent them from being readmitted. According to Tlhowe et al. (2017), the lack of patient family support can lead to a relapse. When the family did not carry out their perceived care role, the patient was susceptible to readmission. However, the carer burden can become detrimental to the carer’s quality of life due to the workload and stressors that arise from caring for a patient with mental health illness. A study in Iran by Akbari et al. (2018) mentioned that the carer’s physical and psychological health could be compromised while caring for an individual with psychiatric problems, which further exacerbates the patient’s disorder due to poor care by family. Javed and Herrman (2017) added that caring for the patient often brought physical, psychological, social and financial problems to the carer. The burden of caring for relatives with mental illness was reflected in several studies. From the literature, the concept of carer burden was defined in the 1980s. However, according to Shamsaei et al. (2015), only recently, interest in the carer role for the psychiatrically ill patient has increased.
Such awareness has led to a focus on the caregiver and the patient, as caregiving has an important influence on the overall quality of the caregiver’s life. In Brunei Darussalam’s context, research into family roles could shed new light on patient treatment and would be beneficial. Life in Brunei Darussalam incorporates the extended family as part of the family system within the National Philosophy of the Malay Islamic Monarchy. Another reason for patient readmission indicated by the participants was the patient not adhering to medication. Nxasana and Thupayagale-Tshweneagae (2014) indicated that poor compliance with medication causes the patient to be re-hospitalised. This finding agrees with previous studies, which highlighted reasons for non-compliance. A study by Semahegn et al. (2020) provided an in-depth map of the psychiatric patient factors for non-adherence to medication: individual patient, social support, treatment and health system-related factors. The same study made it clear that poor family support was a factor leading to patient readmission.
The second theme of the study findings related to the value of psychoeducation as part of the nurse’s role to minimise patient readmission. The participants found this to be a helpful tool and beneficial for patients. Healthcare professionals have widely used psychoeducation in psychiatric settings, as indicated by the nurses in this study. According to Pedersen et al. (2015), psychoeducation is considered a simple therapy for individuals with mental disorders in the healthcare and primary care settings, giving patients theoretical and practical approaches to understanding and coping with their disorder. Srivastava and Panday (2016) added that psychoeducation allows the patient and family to understand the nature, course and prognosis of the disorder. Other studies further illustrated the importance and effectiveness of psychoeducation and its wide use in the psychiatric setting. Psychoeducation is also perceived as a therapeutic tool with a non-pharmacological approach. As McFarlane in Srivastava and Panday (2016) mentioned, one example is the ‘Multiple Family Group Therapy’ model, which aims to involve families in the rehabilitation and aftercare program of patients. Additionally, there is a need for psychoeducation to be culturally sensitive. Several participant nurses highlighted that interference exists towards accepting psychoeducation because of cultural beliefs. Rummel-Kluge and Kissling (2008) showed an improved patient risk of readmission when psychoeducation programs address cultural needs.
The third theme addressed the needs of the patient. While trying to address the needs of the readmitted patient, it is clear that these impact both the patient and nurses. The participant nurses reflected on the effects of psychiatric readmission on their patients. While nurses indicated patients experience “uneasiness” in response to readmission, this was inconsistent with a study by Howard Anderson et al. (2016), which detailed dissimilarities in nurses’ and patients’ attitudes about readmission. Their study found that patients were not upset despite readmission. This needs to be studied further because re-hospitalisation rates will remain elevated if patients are comfortable with readmission. In this study, the participant nurses’ experiences of the impact of readmission were expressed both humanely and professionally.
Despite readmission being stressful in caring for an aggressive psychiatric patient, the nurse’s ability to direct their personal feelings humanely and professionally was astounding. This was borne out in the study by Nontamo (2019). Notwithstanding unbearable conditions related to psychiatric readmission, nurses responded with empathy for the patient and committed to the ethics of the nursing profession. Cleary et al. (2013) stated that humanism was at the core of caring and should be espoused in each professional nurse. However, there is a growing concern on how psychiatric readmission can compromise nursing care. Sobekwa and Arunachallam (2015) found that nurses acknowledged the importance of intervention in response to psychiatric readmission to achieve quality care when dealing with aggressive readmission patients, such as debriefing and peer support. As a result, the significant implications of this study for nursing practice, both nationally and internationally, are the development of appropriate interventions and measures to support and enhance nurses’ ability to care for readmission patients while maintaining and strengthening their quality of care. Such measures may include opportunities for personal and professional growth among nurses and healthcare team members through debriefing sessions. The study also presents the importance of family as a salient factor in preventing patient readmission. To mitigate the carer burden, preparing a consistent, proper and systematic intervention or program to support the family will ensure that the carer is not overly burdened. Future studies are recommended to review current programs and implement culturally consistent and systematic psychoeducation for patients and families.
Limitation
The findings were restricted to psychiatric nurses working in a single psychiatric department in Brunei’s main hospital. Thus, the study results are only pertinent to the population considered and not the entire psychiatric nurses in Brunei. Another consideration is the possibility of response bias since the principal investigator is studying her own workplace. This may lead to a lack of objectivity as an insider researcher.
Conclusion
The study reveals that non-adherence to medication was thought to be a significant determinant for patient readmission. Furthermore, the patient’s family was noted as the primary contributor in reducing patient readmission. Our results stress the importance of the value of psychoeducation and psychiatric community services and their respective roles in supporting the patient and family to minimise rates of psychiatric readmission. Additionally, it was evident that the reasons for psychiatric readmission from the nurses’ perspectives should be acknowledged to improve patient care and mental health services.