18 JPAIR Multidisciplinary Research Healthcare Facilities and Services: Correlates to the Clinical Nursing Care for Patients with Psycho-Behavioral Pathologies in Lanao del Sur OMIRA ABDULBASIT Mindanao State University - Main Campus Marawi City ANIERAIDA H. HASSIM Mindanao State University - Main Campus Marawi City RANDY IAN F. GALLEGO https://orcid.org/0000-0002-7338-3263 randyian_17@yahoo.com.ph College of Health Sciences - Mindanao State University, Main Campus Marawi City, Philippines, 9700 Originality: 95% • Grammar Check: 95% • Plagiarism: 5% ABSTRACT Mental health, for some time, has been a facet downplayed to be of lesser importance due to its very mystical nature causing it to be habitually ignored. Albeit the case, mental illness and its similar disturbances can become so significantly serious that it can encroach on and impair the day-to-day activities of its stricken victims. This study examined the extent of preliminary clinical care provided by nurses to clients with unique psychological needs. It used the descriptive-correlational design through a validated and reliability-tested instrument responded by 113 staff nurses from six hospitals around Lanao del Vol. 33 · July 2018 DOI: https://doi.org/10.7719/jpair.v33i1.603 Print ISSN 2012-3981 Online ISSN 2244-0445 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. 19 International Peer Reviewed Journal Sur. It involved the statistical analysis of data using frequency, weighted mean, and Pearson correlation. In addition, a triangulation procedure was also employed to incorporate qualitative narrative comments of the respondents through follow- up informant interviews and journal writing. The survey revealed that hospitals in the study locale do not have personnel with qualified specializations to attend to the needs of clients with psycho-behavioral manifestations. Moreover, the institutions did not have adequate physical facilities and equipment to aid in the appropriate diagnosis and management of mental conditions. It also showed that the availability of mental health care services, facilities, and personnel were significantly correlated to the extent of preliminary clinical nursing care. Hence, it can be regarded that these factors have a strong bearing and influence on the quality and extent of clinical care received by patients. Keywords — Psychiatric Mental Health Nursing, preliminary clinical care, psycho-behavioral pathologies, descriptive correlational design, Lanao del Sur INTRODUCTION Health, when viewed holistically per se, overlays not just the physiologic well-being; it also has to acutely involve the interplay of progressive mental and emotional responsiveness along with several other parameters. An understanding of what truly constitutes a well-rounded health profile, therefore, involves a comprehensive state of physiological, behavioral, mental and psychosocial wellness that capacitates a person to carry out an array of varying life responsibilities and functions. To date, the recent enactment of Republic Act 11036 or the Mental Health Act of the Philippines has given many directions to the national policy and program of the country to enhance the delivery of mental health services to clients with issues in psychiatric and behavioral well-being. However, considering that the law is relatively new, its implementation and effects are yet to be generally seen. The directives governing the delivery of psycho-behavioral services in the country are so far generically enclosed in several segments of existing laws such as the Penal Code, the Family Code, or the Dangerous Drugs Act. In effect, the nation gets to expend just a meager fraction of its overall budget allocation on mental wellness programs; sparing a staggering share of it mostly on operations and maintenance of psychiatric facilities. In an article released by the Essays UK in 2013, the dismal country-wide health setup revealed that in most regional settings, no provincial facilities are structured 20 JPAIR Multidisciplinary Research for the purpose of in-patient psychiatric confinement. Local government-owned hospitals hold no critical psychiatric units due to poor budgetary resources making access to mental health facilities across the Philippines a compelling obstacle. What seems to be even more challenging in this setting is that there are not enough health workers who are expressly skilled in handling the individual needs of these types of clientele. The article pointed out that “one glaring setback in the field is that the current primary health care staff are not specifically trained on mental health.” Comparatively, the present state of mental health systems in the country does not differ much when examined alongside with its other ASEAN neighbors. In terms of legal provisions, there is also no existing mental health legislation in Indonesia (WHO, 2011). It is similar to the case of Myanmar where most legal policies on the delivery of mental services are covered in other general welfare statutes or disability laws. On the other hand, countries such as Malaysia, Thailand, and Singapore have officially approved national directives and manuals on the management and treatment of mental disorders. The Mental Health Act in Malaysia, for instance, has brought forth tremendous development to the health workers, service users, and all other stakeholders in the country (Chong, Mohamad & Er, 2013). When it comes to mental health expenditures, available literatures bare that Myanmar expends less than one percent (0.3%) of its health care expenditures towards mental health (WHO AIMS Report Myanmar, 2006) while Thailand approximated 3.5% percent of its healthcare budget in 2004 towards mental health services (WHO AIMS Report Thailand, 2006). Challenges being commonly faced by most Southeast Asian nations revolve around insufficient government resources to propel mental services and programs to its full implementation. Majority of primary health care doctors and nurses in Indonesia have been reported not to have received official in-service training on mental health within the last five years (WHO, 2011). Similarly, Cambodia is confronted with the same challenge of poor mental health and limited resources for care (Olofsson, Sebastian, & Jegannathan, 2018). Low awareness and mental health literacy coupled with an ardent devotion to the conventional multicultural belief systems in Malaysia are seen as confounding threats to caregivers, mental health program users, and providers (Chong, Mohamad & Er, 2013). Locally, in the Lanao del Sur province, in particular, no established mental healthcare agency has been instituted to cater to the exigencies of clients with behavioral issues. With respect to the country-wide profile, ARMM holds no regional in-patient mental facility. This fact also actually holds for most of the hospital venues in Mindanao. Conde (2004), in his study cited that even 21 International Peer Reviewed Journal at the turn of the new millennium, “the appointed Secretary of Health in his trips around the country to assess the health care delivery system, have seen the deplorable conditions of one particular hospital in Mindanao, where half-naked patients were allowed to roam the grounds or were left immobilized in corridors.” In any care setting where acute management of psychological impairment is evident, the role of the nurse navigates both in addressing the actual and potential needs of the client. The American Nurses Association (2012) clearly asserts the phenomena of concern for nurses: the maintenance of optimal health and well-being and the prevention of psychobiologic illness, assessing and assisting the self-care limitations of clients, symptom management associated with psychopharmacologic intervention and treatment regimen, and providing support for deficits in functioning associated with emotional stress and anxiety. This study, therefore, aimed to explore the extent of preliminary clinical nursing care provided by nurses working in the locale to clients with unique psychological presentations. It is of interest to find out how the the provision of mental health care is facilitated in regional settings despite the seeming insufficiency in terms of resources and programs. FRAMEWORK Based on the different concepts carted off by the researchers from a wide review of the literature, the outline framework was conceptualized. This is to show the relationship of the personal profile, professional profile, and institutional profiles on the extent of nursing care being provided to clients with psychological and behavioral symptoms and pathologies in the different hospitals in Lanao del Sur. 22 JPAIR Multidisciplinary Research OBJECTIVES OF THE STUDY This study aimed to (1) investigate the extent of preliminary clinical nursing care imparted by registered nurses to clients with unique psychological presentations. It is of interest (2) to find out how local nurses are rendering their nursing interventions in light of the aforementioned deficiencies in our healthcare system. Moreover, it also (3) endeavored to evaluate the extent of professional nursing performance to shed light on the quality of care, education, and resource utilization in mental health care delivery. METHODOLOGY Research Design The data was generated from a cross-sectional, researcher-administered survey of 113 respondents from the randomly selected hospitals in Lanao del Sur, Philippines. A descriptive correlation research design was selected to fulfill the objectives of the inquiry. It is descriptive in purpose, gathering salient personal, professional and institutional data to describe the respondents’ profile and correlational that it tested the relationship between the profile and the extent of the preliminary clinical care provided to clients with psycho-behavioral symptomatology. In addition to the above process, a triangulation procedure was also employed to incorporate qualitative narrative comments of the respondents through follow-up informant interviews and journal writing. Research Site The study commenced on August of 2016 until June 2017 and was conducted in six (6) private and government hospitals which were geographically distributed around the province of Lanao del Sur. These six hospitals were chosen on the basis of being considered as an operational, private, and government-operated facilities equipped to attend to the preliminary health care needs of the general population of Lanao del Sur with a minimum primary healthcare facility status and more than 20-bed capacity patient coverage. Likewise, they were checked for feasibility in terms of organizational structure and accessibility to clients. Hence, they qualify in the eligibility for study inclusion. 23 International Peer Reviewed Journal Research Respondents Registered Nurses were primed as main respondents in the study because they possess the legal mandate as healthcare providers and advocates of clients with diverse clinical needs, including psychiatric care. Hence, they are the ones expected to manage the patients’ various health affairs including but not limited to the provision of preliminary mental health care. Thus, enabling them to meet the inclusion criteria. To be eligible as respondents, these nurses should be: 1.) Current staff members of the selected hospital regardless of their employment status; and 2.) have taken care of client(s) with reported or diagnosed case of psycho-behavioral pathology. Criteria 2 was determined using a pre-survey of the profile of all nurses employed in the randomly selected hospitals. An item in the pre-survey tool specifically asked for the nurse’s history and prior experience in handling clients with known psycho-behavioral symptoms. The researchers further identified at least 3-5 respondents per hospital through a purposive selection scheme and were tapped to take part as key- informants in a follow-up interview. All those who formed part of this group were asked to answer an essay-type question constructed for them to describe the extent and nature of psychiatric management provided by them for their patients not otherwise explicated in the survey forms. Instrumentation of Data Collection The research instrument was a survey questionnaire composed of five (5) sections with a total of 123 items. The parts of the questionnaire constructed by the researchers framed the set of questions to determine the personal, professional, and institutional profiles of the respondents to obtain the information such as the respondents’ work summary and degree of professional competence. The institutional profile and extent of preliminary care delivered would determine the presence of health facilities, services, and quantity of personnel and the degree to which they are rendered to the mentally ill clients. A panel of experts composed of the panel members, validators, and the statistician was requested to evaluate the content validity of the research instrument. The experts were asked to assess the individual item in the questionnaire to test if they were applicable and appropriate in relation to the study problems and whether the items would sufficiently measure all aspects of the construct. Thus, comments, suggestions, and recommendations of the experts were acknowledged. 24 JPAIR Multidisciplinary Research Validation of Instruments After all the validated data has been gathered, the results were then tested for Content Validity Ratio. The result of the tabulation of CVR was based on its standard corollary in which the score of 0.7 – 0.9 was Retained, 0.6 – 0.5 Revised and 0.4 – 0.1 was considered Rejected. Consequently, the researchers conducted a pilot study with 15 Staff Nurses from the study locale to subject the instrument for Cronbach’s Alpha Reliability Coefficient. For research purposes, a useful rule of thumb is that reliability should be at least 0.70 and preferably higher. Hence, in the test instruments of the study, the reliability of the survey instrument is 0.987 or 98.7%. Ethical clearance was then secured from the MSU-College of Health Sciences Research Committee for the field data collection to commence. Informed consents were attached to the research questionnaires to serve as a guide for respondents to be reviewed of their rights and assured of their anonymity and privacy throughout the entire course of the study. Data Analysis Data were then treated using descriptive statistics: frequencies, and percentages for the socio-demographic variables; and means and standard deviations for the extent of preliminary nursing care. Pearson correlation analysis was used for the assessment of relationships among quantitative variables. Statistical significance was considered at p-value ≤ .05 with a critical value of 2.000. The content of each scale was analyzed, categorized, and then coded by the researcher. Subjects’ responses to each category were tabulated separately by using the Statistical Package for Social Science (SPSS) version 19. RESULTS AND DISCUSSION Table 1 shows the socio-demographic data of the study sample. Female respondents, who comprised the majority (88) of the sample or 77.90%, outnumbered the male nurse respondents. This high proportion of female nurses in hospital settings and probably in all types of healthcare environment is not a novel scenario in nursing practice; it is common place to assert that nursing is predominantly a gendered profession. This correlates with the literature that indicates that the nursing workforce in the health sector is mostly female (WHO, 2003). 25 International Peer Reviewed Journal The majority of the respondents have an age bracket of 23 to 28 years and were mostly single (71.70%). Relatively, it is also from this age frame that most beginning registered nurses start their careers as entry-level practitioners in the nursing workforce. Within this age range, they are able to secure their license to practice by passing the Nurse Licensure Examination (NLE), which is usually immediately upon completion of their baccalaureate program. It can be confidently assumed that this is the typical career route or path taken by nursing graduates. Furthermore, the biggest portion of the respondents (58.41%) in the study has a monthly income of P9, 000.00 and below per month. This is a far cry from legislative stipulations which provides for the minimum compensation track for nurses in the country: Republic Act 9173, otherwise known as the Philippine Nursing Act of 2002, SEC. 32, Salary states that – entry-level nurses in public health institutions shall receive compensation not lower than salary grade 15 (at least P 24, 887.00). Majority (72.60%) of the respondents has Islam as their religion whilst the remaining fell in the Christianity and others category. In terms of ethnic affiliation, more than half (65.50%) were Meranaos, and the rest of the samples represented the Cebuano, Maguindanao and other tribes. This finding is to be expected considering that the research locale chosen is Lanao del Sur. The Province of Lanao del Sur is a province in the Philippines located in the Autonomous Region in Muslim Mindanao (ARMM). The people of Lanao del Sur are predominantly practitioners of Islam. 26 JPAIR Multidisciplinary Research Table 1. Frequency Distribution of the Studied Sample According to their Personal Profile Characteristics. (No. = 113) Variables No. % Age Group 22 and below 13 11.5 23 – 28 70 61.9 29 – 34 23 20.3 35 and up 7 6.2 Gender Male 25 22.1 Female 88 77.9 Civil Status Single 81 71.7 Married 27 23.9 Widowed 3 2.7 Divorced 1 0.9 Others 1 0.9 Ethnic Affiliation Meranao 74 65.5 Maguindanaon 5 4.4 Cebuano 19 16.8 Others 15 13.3 Religion Islam 82 72.6 Christian 29 25.7 Unaffiliated 1 0.9 Others 1 0.9 Monthly Income 20,000 Php Or More 19 16.81 15,001 Php – 20,000 Php 12 10.62 10,001 Php – 15,000 Php 16 14.16 5,001 Php – 10,000 Php 66 58.41 5,000 and Below 0 0.00 In terms of the professional profile of the respondents, the great majority were Bachelor’s degree in Nursing graduate (88.50%). In most instances, fresh graduates or so-called initiates usually comprise the novice population in healthcare settings, thus, the critical need for socialization and resocialization to extend or enhance the gains made from the socialization provided by the nursing school attended. Socialization into the organization is crucial for the novice professionals to ease the transition into their professional roles, minimize 27 International Peer Reviewed Journal frustrations, awkwardness, and conflict on the clinical floor, and to instill in them high morale and enthusiasm for the organization and commitment to its goals (Cable & Parsons, 2001; Marquis, 1988). Albeit the fact that nurses have been holistically honed to cater to the needs of all kinds of clienteles, psychiatric clients included, as the Bachelor’s degree curriculum provides for instruction and training on this aspect of nursing care, the exposure and clinical rotation can be considered limited. Specific nursing knowledge and skills need to be learned scrupulously for the health provider to render effective and condition-congruent nursing care. Particularly in the case of mental health care delivery, most finishers of the undergraduate degree in Nursing are considered generalist practitioners who are trained only with the fundamental aspects of care for patients with psychiatric conditions. Further advanced training and specializations in mental health care are needed to provide streamlined interventions for these types of clientele. Subsequently, in terms of their employment, these nurse-respondents were mostly employed under the non-permanent tenure (54.80%) either as contractual, job-order or volunteer status. On the average, these nurses have served their current base hospitals for a length of 1 year and below (41.60%). Consistent with the findings on the respondents’ present length of service, the researchers presumed that the reason why there is a high percentage of respondents who were employed under the non-regular status employment is that, most beginning nurses are not hired instantly for regular appointments in most hospital settings since they first go through a period of orientation and training to familiarize and slowly integrate into the roles and functions of a regular staff nurse. Subsequently, through mentoring activities, most novice nurses gain the necessary competence and development that will help them prepare to step up to higher positions in the professional ladder (Gallego, 2014). This is supported further in other literature as “individuals who have been mentored report a variety of beneficial outcomes including higher promotion rates, salary, job and career satisfaction, organizational socialization, and organizational commitment, and lower job stress. Consequently, the framework of mentoring programs has seen to affect professional outcomes for new nurses positively; this holds particular bearing even amongst those who have been coached under informally structured activities. Studies further suggest that similar mentoring undertakings are also favorable to the career and psychosocial health of neophyte nurses. However, its effect on job satisfaction is not as widely pronounced as compared to other professionals and disciplines (Blastorah, 2009). 28 JPAIR Multidisciplinary Research Table 2. Frequency Distribution of the Studied Sample According to their Professional Profile Characteristics (No. = 113) Variables No. % Highest Educational College Graduate 100 88.5 Attainment Master’s Degree Level 6 5.3 Master’s Degree Graduate 6 5.3 Others 1 0.9 Length of Service 1 Year And Below 47 41.6 1 Year & 1 Month – 2 Years 19 16.8 2 Years & 1 Month – 3 Years 16 14.2 3 Years & 1 Month – 5 Years 15 13.3 5 Years And Above 16 14.2 Employment Status Permanent/Regular 51 45.1 Contractual 46 40.7 Volunteer 12 10.6 Job Order 4 3.5 On the context of the institutional profile, three parameters were assessed: the availability of mental health care facilities, availability of services, and the availability of personnel/manpower. The data collected revealed that in terms of facilities, the different participating hospitals did not have adequate mental imagery visualizers, medical diagnostic apparatuses, and hospital-owned ambulances. These data were also counter-verified by ocular surveys by the researchers. 29 International Peer Reviewed Journal Table 3. Frequency Distribution of the Studied Sample According to their Institutional Profile Characteristics. (No. = 113) FACILITIES Availability Mental Imagery Visualizer Computed Tomography Scan none Magnetic Resonance Imaging none Positron Emission Tomography none Medical Diagnostic Apparatus present Transportation Vehicle inadequate Room Wards for Psychiatric Clients inadequate PERSONNEL Psychiatrist none Psychologist none Trained Psychiatrist Nurse none Vocational Rehabilitation Specialist none In light of all the perceived insufficiencies vexing our local health care facilities in addressing our regional mental health needs, national allocation of resources on the aspect of mental care has, for the longest while, been a perennial challenge. The Philippine mental healthcare statistics show that there are only around 7.76 hospital beds and 0.41 licensed psychiatrist for every 100, 000 patients. Presently, there are: 2 mental institutions operating in the country; 46 facilities catering to about 124.3 users/100,000 general population on an outpatient basis; 4-day treatment facilities treating 4.42 users/100,000 population; 19 community-based inpatient centers providing .61 beds/100,000 population; and 15 residential-type, custodial care accommodating clients at a rate of 0.61 beds/100,000 cases. The only metro-based psychiatric hospital in the country, the National Center for Mental Health has a bed capacity of 4,200, the rest of the facilities are distributed along the other regional cities in the country. Furthermore, psychotropic medication use is limitedly available; more so in non- physician based primary health care units (WHO-AIMS Report Philippines, 2005). This dismal condition reflecting our limited national resources to promote mental health and cure mental illness is further reinforced by the verbalizations 30 JPAIR Multidisciplinary Research expressed by some respondents during the interviews conducted and the responses provided in the journal. In one instance, a nurse in an interview state: “It is hard to implement psychiatric nursing interventions when we do not have the right equipment to actualize our care plans. We all know that psych patients are different from regular patients, right? Their needs are unique. So, if we don’t have the right facilities for them, then it’s going to be difficult to manage their needs. (Nurse A from Hospital 2, Interview response, August 15, 2017) In terms of mental health care services, 75.86% of the participants responded that services such as counseling, milieu therapy, self-care activities, psychobiologic interventions, health-teachings, health promotion, and maintenance are being provided and rendered by them in their institutions because of their availability. The researchers contend that such high response can be attributed to the nature of the services being rendered. Majority of the indicators under the services have to do with the provision of health education and therapeutic communication to all clients which are predominant responsibilities of nurses in whatever type of care setting. Patient education does not warrant high academic training and specialization, as most generalist practitioners can deliver such function and task. The quality of mental health care services usually takes predication on sound protocols, guidelines, and standards which highlights the responsiveness of the delivery system to address the needs of clients and strengthen their mental health welfare. It is, therefore, crucial to have a body that would help determine whether the standards and training are consistent to set and establish protocols. In the country, the Department of Health is the regulating agency that is assigned for licensing of mental health institutions. In terms of mental care services, accreditation is facilitated by the PhilHealth; although not all facilities submit for such quality assurance process. It is also importuned that international accrediting bodies such as the ISO and JICA do not oversee the accreditation of mental health services and facilities. Moreover, the academic arm of the Philippine Psychiatric Association (PPA) known as the Philippine Board of Psychiatric is the body in-charged of providing certification for psychiatrists to become diplomats. It is the same organization that sets the standards and protocols followed for training programs and modules in the field and practice of psychiatry. As for the other mental health practitioners, they receive their educational instruction from academic institutions as generalists and are then further trained to specialize in 31 International Peer Reviewed Journal mental health after being hired as a mental health worker (Health Policy Notes, 2008). For the availability of manpower and personnel, as illustrated in the table above, most hospitals in the locale do not have staff members that have specializations in the appropriate care for psycho-behaviorally affected clients. For instance, no psychiatrists, psychologists, trained psychiatric nurses, and registered guidance counselors are employed in their institutions. In available Philippine studies, the total number of human resources working in mental health facilities or private practice per 100,000 general population is 3.43. The breakdown according to profession is as follows: 0.42 psychiatrist, 0.17 other medical doctors (not specialized in psychiatry), 0.91 nurses, 0.14 psychologists, 0.08 social workers, 0.08 occupational therapists, 1.62 other health or mental health workers (including auxiliary staff, non-doctor/non-physician primary health care workers, health assistants, medical assistants, professional and paraprofessional psychosocial counselors). Thirty percent of psychiatrists work only for government-administered mental health facilities, 59% work only for NGOs, for-profit mental health facilities and private practice, while 11% work for both sectors. Fifty-six percent of psychologists, social workers, nurses, and occupational therapists work for government-administered mental health facilities, 26% work only for NGOs, for-profit mental health facilities and private practice, while 18% work for both sectors. The figures provided are best estimates based on official registration and data from professional associations (WHO-AIMS Report Philippines, 2007). The concentration of mental health professionals in Metro Manila was noted by Dr. Melissa Mariano, a psychiatrist, and a member of the PPA. According to her, 90% of practicing psychiatrists are in Metro Manila. This suggests that while all the bills advocating for mental health emphasized the delivery of mental health services in all parts of the country, this is not what is actually in practice (Castro, Capinpin, Esteban, Fojas, & Luis, 2014). This seemingly disproportionate ratio of available practicing mental health professionals and their served population is seriously compromising our care systems in the country. Fewer personnel may also mean less quality of work and poor delivery of care services. However, a more positive outlook is surfacing as statistics according to Castro, Capinpin, Esteban, Fojas, & Luis (2014) records the number of professional graduates per year in academic and educational institutions per 100,000 is as follows: 0.011 psychiatrists, 3.43 medical doctors, 43.22 nurses, and 21.36 nurses with at least 1-year training in mental health care. 32 JPAIR Multidisciplinary Research In another dimension, six areas were also covered in this inquiry to highlight the extent of preliminary nursing care provided to clients with mental and behavioral problems. These are counseling, milieu therapy, self-care activities, psychobiologic interventions, health-teachings, health promotion, and maintenance. In summary, Table 4 illustrates that the nurse-respondents of the selected hospitals in Lanao del Sur generally considers the extent of implementation of the six nursing care areas tested under the dependent variable as frequently done. They described the extent of demonstration and performance of counseling, milieu therapy, self-care activities, psychobiologic interventions & health- teachings, case management, health promotion and maintenance as generally emphasized in about 75% of the time in their respective clinical areas. Table 4. Summary on the Extent of Preliminary Clinical Care provided to Clients with Psycho-behavioral Symptoms Preliminary Clinical Care on the Context of: MEAN DESCRIPTIVE RATING 1 Counseling 3.676 Frequently 2 Milieu Therapy 3.677 Frequently 3 Self-Care Activities 3.679 Frequently 4 Psychobiologic Interventions and Health Teachings 3.753 Frequently 5 Case Management 3.639 Frequently 6 Health Promotion and Maintenance 3.678 Frequently Average 3.684 Frequently Scaling: 4.21-5.00– “Whole”, 3.41-4.20– “Frequent”, 2.61-3.40– “Occasional” 1.81-2.60– “Rare”, 1.00-1.80- “Never” Aside from the above clinical care, the WHO (Geneva, 1996) stated that Mental Health Care should contain 10 basic principles which are: Promotion of mental health and prevention of mental disorders; Access to basic mental health; Mental health assessment (diagnosis, choice of treatment, determination of competence); Provision of lesser restrictive type of mental health care; Self- determination; Right to be assisted; Availability of review procedures; Automatic periodic review; Qualified decision maker; and Right of the rule of law. Another important presentation in this part of the discussion is the possible relationships or correlations between the sets of variables previously identified. 33 International Peer Reviewed Journal Hence, attention is further focused on an attempt at identifying the relationship between the personal, professional, and institutional profile of the respondents versus the extent of the preliminary clinical care that they provide to their psychologically vulnerable clients. The results are depicted in Table 5 to 8. As revealed in the findings, all personal profile variables, namely age, sex, civil status, religion, monthly income, type and size of the family have no significant correlation with the extent of preliminary clinical care in terms counseling, milieu therapy, self-care activities, psychobiologic interventions, health-teachings, health promotion, and maintenance. When tested at 0.05 level of significance, the p-values obtained were all less than the critical value. Only the ethnic affiliation was significantly related to health promotion and maintenance. Table 5. Relationship Between Personal Profile and Extent of Clinical Care to Clients in terms of Health Promotion and Maintenance Relationship Correlation coefficient p-value Age Health Promotion and Maintenance 5.607 0.231 Sex 1.219 0.544 Civil Status 0.717 0.699 Ethnic Affiliation 11.660 0.020* Religion 3.168 0.205 Monthly Salary 2.241 0.691 Type of family 4.774 0.311 Size of family 0.570 0.997 * Significant at 0.05 level of significance This implies that the respondents’ ethnic and cultural background has an influence to the extent and perhaps the degree of clinical care that they can render to their clients with psycho-behavioral manifestations. Hence, the researchers are convinced that the implication of this correlation should be considered by institutions to particularly intensify and emphasize the need to encourage their nurses to become transculturally competent and sensitive to the diverse and unique cultural backgrounds of their clients with psychological disabilities. According to the reviewed literature, Filipino perception of mental illness is very much influenced by our inherited system of cultural beliefs and practices. Castro, Capinpin, Esteban, Fojas, & Luis (2014) cited that aside from the lack of availability of mental health services in the rural areas, Filipinos’ perceptions of 34 JPAIR Multidisciplinary Research mental health care may affect the procurement of mental health services. Filipino families whose members suffer from mental illnesses initially blame the patient for possessing the illness. The patient is shunned by sayings such as: “Nasa utak mo lang yan” (It’s all in your head) or “Mahina lang loob mo” (Your will is just weak). Therefore, the expected cure is for the patient to help himself/herself. Moreover, these families usually keep the condition of the patient as a secret because of the stigma attached to having a mental illness. Moreover, mental illnesses in rural communities are also perceived to stem from spiritual factors and paranormal activities such as “kulam.” This perception of curses and witchcraft encourages families to seek faith healers (albularyo) instead of mental health professionals. For example, the study by Brolan, van Dooren, Taylor Gomez, Fitzgerald, Ware, Lennox (2014) on intellectual disability and treatment choices in Negros Occidental, they discovered that the preferred treatment of choice was going to the suranho (shaman or medicine man). “Informants explained that family members contact the suranho to cast out ‘the bad spirit’ that has possessed the body of the person with intellectual disability, due to the belief that the person with intellectual disability became possessed after an unfortunate encounter with a ghost or spirit” (Brolan, van Dooren, Taylor Gomez, Fitzgerald, Ware, Lennox, 2014). Table 6 further highlights the relationship between the professional profile and the extent of the preliminary clinical care provided to clients. It could be surmised based on the result that the educational attainment, length of service and employment status has no significant relationship with clinical care in terms of counseling, milieu therapy, self-care activities, and health promotion and maintenance. When tested at 0.05 level of significance, the p-values obtained were all less than the critical value. However, it was found out that relevant seminars and trainings attended especially those that are conducted at the regional levels have a significant relationship with psychobiologic interventions, health teachings, and case management. 35 International Peer Reviewed Journal Table 6. Relationship Between Professional Profile in terms of Relevant Seminars and Trainings Attended and Extent of Clinical Care to Clients Relationship Correlation coefficient p-value Relevant Regional Seminars and Trainings Attended Counselling 0.052 0.588 Relevant Regional Seminars and Trainings Attended Milieu Therapy 0.064 0.499 Relevant Regional Seminars and Trainings Attended Self-care activities 0.084 0.374 Relevant Regional Seminars and Trainings Attended Psychobiologic interventions Health Teaching 0.196 0.037* Relevant Regional Seminars and Trainings Attended Case Management -0.223 0.017* Relevant Regional Seminars and Trainings Attended Health Promotion and Maintenance 0.088 0.355 *Significant at 0.05 level of significance It can be gleaned from the above results that psychobiologic interventions, health teaching, and case management are influenced by the nurses’ participation in relevant seminars and training at regional levels. The researchers ascribe this significant correlation to the fact that most of the patients involved in the care are coming from the locale itself, communities of Lanao del Sur. As such, they are constituents of the Meranao community whose culture and practices are unique and distinct from that of other tribes. Hence, for healthcare providers to be able to give the best, suitable, and apt psychobiologic interventions and health teachings to these patients, they have also to be exposed to training and conferences that deals much with the Meranao way of life, their perception of mental illness and their approaches to mental health care. In relation to the provision of health teachings to Meranao clients, one respondent keenly depicted his experience and expressed that: 36 JPAIR Multidisciplinary Research “I am Visayan and I am working here in Marawi City. What I find very challenging in my job is my inadequate exposure to the culture that they have here. Syempre dili ko taga diri, so kailangan ko makahibalo sa ilang culture, sa dialect ug uban pa. (Of course, I am not from here, so I really need to learn about their culture, dialect and other things.) I have to be effective in my work, especially in handling psych patients. Lisod na! (Its hard). I think I need more education about them.” (Nurse B from Hospital 4, Journal Response, August 18, 2016) Table 7 illustrates the relationship between the institutional profile and the extent of the preliminary clinical care provided to clients. The institutional profile was characterized using three indicators, namely: availability of mental health care facilities, availability of mental health care services and availability of mental health care personnel. Relationships were then statistically tested between these profile indicators versus the extent of clinical care in terms of counseling, milieu therapy, self-care activities, psychobiologic interventions and health-teachings, case management, health promotion, and maintenance. It can be gleaned from the table below that availability of mental health care facilities was significantly correlated to the extent of preliminary clinical care in all its areas, to wit: counseling, milieu therapy, self-care activities, psychobiologic interventions & health-teachings, case management, health promotion, and maintenance. Table 7. Relationship Between Institutional Profile in terms of Availability of Mental Health Care Facilities and Extent of Clinical Care to Clients Relationship Correlation coefficient p-value Availability of Mental Health Care Facilities Counselling 10.108 0.006* Availability of Mental Health Care Facilities Milieu Therapy 11.346 0.003* Availability of Mental Health Care Facilities Self-care activities 23.992 <0.001* Availability of Mental Health Care Facilities Psychobiologic interventions Health Teaching 14.325 0.001* Availability of Mental Health Care Facilities Case Management 28.303 <0.001* Availability of Mental Health Care Facilities Health Promotion and Maintenance 24.888 <0.001* *Significant at 0.05 level of significance 37 International Peer Reviewed Journal It can, therefore, be regarded that the availability of mental health care facilities can have an influence on the extent of clinical care to clients with psycho- behavioral problems. The delivery of long-term mental health care for patients with acute mental disorders has always been the perennial problem in the country, most especially that community health services takes very gradually to develop due to multiple confounding factors. Some barriers are linked to policy level: inadequate mental health policies and laws, insufficiency of funds, procedural discrimination against patients battling with mental illness, and limited health insurance. Another barrier centers on health system issues: distribution of resources do not get evenly released from larger to smaller institutions causing under-investment in services on the community level, poor integration of services with the national mental health system, poor integration of services with the other existing social care systems like housing and employment services, poor coordination between statutory and non-statutory mental health services, and not enough training of personnel all throughout the systems (WHO, 2003). In any case, there remains to be a pressing need to pursue better strategic initiatives still to deliver accessible, competent and superior quality long-term mental interventions to all patients who suffer from debilitating mental illnesses in Europe. Although the glaring reality is that, for the most part of the world especially among developing nations, clients living with psychiatric disabilities continue to live in mental institutions where there are poor living conditions, insufficient medical assistance and chronic abuse of human rights (Muijen, 2008). In other countries, resources allotted for new services are not very much visible, and responses to psychosocial needs are limited. Even in countries where the implementation of deinstitutionalization is not a novel concept, there still exist issues concerning the increasing rate of “reinstitutionalization” of patients facing a longer-term and more complex confinement need (Priebe et al., 2005). This phenomenon is termed as the “OATS” (out of area treatments) issue in the UK, where concerns on the quality and safety of care in certain institutions are being pointed out, together with the sense of social displacement of patients after having been isolated away from their families plus the other factors such as poorly coordinated assessment system to review patients ‘present needs and placement funding (Ryan, Pearsall, Hatfield & Poole 2004). CONCLUSIONS The findings of this study derived from the responses and data gathered from the respondents suggest that the Philippines still has to continue on its effort to 38 JPAIR Multidisciplinary Research continuously improve its healthcare sector, paying particular emphasis on the aspect of mental health. The country has to tirelessly pursue and affirm the WHO vision of ensuring health for all, by making sure that health is inclusive in that, to speak of health is to speak of its encompassing coverage of not just physical but emotional, social, and psychological wellness converging in one body and system. To make headway in terms of health, relevant legislation has to be enacted so that resources, processes, and structures are set in place, and health reforms are started in earnest as it is most necessary now more than ever. For it to be sustained, it is important to decentralize these reforms and make it visible across the entire country. In the Lanao Sur province, for instance, the research findings revealed the insufficiency of the existing mental health facilities and personnel to cater to the needs of the informed population. The lack of treatment equipment and counseling areas may pave the way for the provision of inappropriate, poor quality services to the clientele. This might only make the status of patients’ worse, making them feel more helpless about their conditions. On the other hand, the apparent inadequacy in the perceived competence of nurse-generalists on the aspect of rendering clinical care to psychologically disturbed clients is a gaping chasm that points out a lot of implications in the quality of professional practitioners that this Philippines is producing. Essentially, when one is not holistically and all-inclusively equipped with the aptitude and proficiency that is expected of him/her in the practice of his/her profession, he/she is deemed to be unskilled and incompetent to carry out her/his roles, functions and responsibilities. To be able to endow the nursing goal to enforce health, it is essential to aid the number of personnel in the hospitals with trained experts who are capable of handling psychologically ill clients to attain mental health and integrate themselves to the clinical care world. Hence, the researcher believes that there is a need to strengthen and intensify the equitable access to appropriate assessment and treatment by the informed populace with regard to their mental health conditions. This can be ensured by training staff members to have the appropriate skills to work professionally and effectively with people who are vulnerable and at high risk of developing mental- behavioral disorders. The researchers recommend that Registered Nurses, who are presently working in acute, medical-surgical inpatient settings, should still actively receive training and education in caring for psychologically impaired clients. They should act as an advocate and must be sensitive in communicating with mentally 39 International Peer Reviewed Journal ill clients. 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