Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

The effect of a community mental health training program for

multidisciplinary staff☆,☆☆
⁎
Bing Xiang Yanga, , Teresa E. Stoneb, Scott A. Davisc
a
Faculty of School of Health Sciences, Wuhan University, Wuhan, China
b
Faculty of Nursing, Chiang Mai University, Thailand
c
Staff of Hunter New England Mental Health Center, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Primary health workers play a critical role in providing health education to people with mental
Community health education disorders. In China community health workers working with people with mental health problems lack experi-
Interdisciplinary education ence and training in this area. Additionally, coordination between hospital and community staff is not well
Training program established. The aim of this study was to provide an interdisciplinary community mental health training program
Mental health
and to evaluate the effect of the training on staff knowledge about mental health and confidence in their roles.
Methods: A three-day community mental health training program was offered specifically for interdisciplinary
mental health professionals. Using a one-group pre-test post-test design, participants completed a self-assessment
of mental health concepts and program evaluation which included asking participants to rate their satisfaction
using a five-point Likert scale and to respond to open-ended questions.
Results: Forty-eight participants including health professionals from colleges, hospital and community health
centers were recruited. Only 8.7% of participants had ever received community mental health training. Post-test
evaluation demonstrated improvements in knowledge, and most participants were very satisfied with the pro-
gram.
Conclusion: The findings indicate that this brief interdisciplinary training program had a positive effect in im-
proving knowledge about community mental health concepts and confidence in dealing with people with mental
health disorders for multidisciplinary staff working in primary health care areas.

Introduction unavailability of community recovery or rehabilitation services; lack of

Mental disorders have drawn increasing attention globally. In terms
of global burden of disease, mental and substance use disorders was the
fifth leading contributor in 2010, when measured by disability adjusted
life years (Ferrari et al., 2014). In China, approximately one hundred
million people are living with mental disorders; half of them live in the
community and do not receive any treatment (Feng & Liu, 2014). Al-
though people with mental health problems who have received ap-
propriate treatments may make a clinical recovery, not all make a
complete recovery and fully participate in society (World Health
Organization [WHO], 2015). This is evident in China: a survey con-
ducted in Beijing found most people lost their jobs or retired ahead of
schedule due to mental disorders (Bao & Chen, 2011). When people
with mental disorders return to their community, they suffer a high rate
of relapse for a variety of reasons. In China, irregular medication usage;
family and social support; and high self and social stigma, have been
identified as the key causes of relapse (Ran et al., 2003; Yang, Phillips,
Licht, & Hooley, 2004; Zhan, Zhang, Yu, & Wang, 2010). A local study
in Wuhan found that only 62% of people with severe psychotic dis-
orders regularly took prescribed medication (Li & Li, 2015).
Having competent community health professionals to manage and
care for those with mental disorders is critical for recovery (Robiner,
2006). It is essential to provide community-based services to help
people maintain hope and achieve goals and aspirations (WHO, 2017).
In China, community service for people with severe mental illness has
been one of the ten national basic public health services since 2009
according to the National Health and Family Planning Commission of
the People's Republic of China [NHFPC] (2009). However, unlike other
health services the tertiary mental health system (community - district -
municipality) has not yet been established and the community mental

☆
The authors report no actual or potential conflicts of interest.
☆☆
In addition, all authors approve the content of the manuscript and have contributed significantly to the research involved.
⁎
Corresponding author at: School of Health Sciences, Wuhan University, No. 115 Donghu Road, Wuchang, Wuhan 430071, China.
E-mail address: 00009312@whu.edu.cn (B.X. Yang).

https://doi.org/10.1016/j.apnu.2017.12.007
Received 17 August 2017; Received in revised form 5 December 2017; Accepted 13 December 2017
0883-9417/ © 2017 Published by Elsevier Inc.

Please cite this article as: Yang, B.X., Archives of Psychiatric Nursing (2017), https://doi.org/10.1016/j.apnu.2017.12.007
B.X. Yang et al.
health system is not well developed (NHFPC, 2008). This guideline also
advocates for the training of public health care providers to improve
their ability to provide effective care in mental health disorder man-
agement and community rehabilitation.
China has a critical shortage of mental health workers (Xiang, Yu,
Sartorius, Ungvari, & Chiu, 2012). A study in Hangzhou reported that
the psychiatrist-to-resident ratio in community health centers was only
1.67/10,000 (Luo, Sun, Song, Xu, & Wang, 2015) and psychiatrist-to-
people with mental disorders was 1.16/10,000 in nationwide (Xiang
et al., 2012). A study in northern China found that only 3.2% of mental
health workers in communities had a baccalaureate or higher degree,
and only 37.1% had received relevant training in community mental
health concepts (Lv et al., 2014). This situation is worsened by a
shortage of professional psychiatric clinicians and community mental
health resources which makes mental health care out of reach for the
majority of residents (NHFPC, 2008; Xiao, Yi, Ran, & Zheng, 2014). A
Beijing study indicated that out of a total of 362 community nurses,
only 28.73% were familiar with mental health management and the
majority expected to receive community mental health training (Guan,
Yin, & Xu, 2010). The deficiency in knowledge and skills of primary
health care providers in mental health recovery, managing emergen-
cies, proper discharge guidance, and case management complicates the
situation.
National and international mental health programs have demon-
strated that training health staff will improve the quality of mental
health care (Jenkins, Mendis, Cooray, & Cooray, 2012; Li et al., 2015;
Sadik, Abdulrahman, Bradley, & Jenkins, 2011). A training program for
community health workers in India showed that the participants'
knowledge of mental health improved after the training (Armstrong
et al., 2011). Although the Chinese government requires mental health
specialists in public hospitals to work in community centers, few
community health centers have these specialists (Wang, Li, Li, Shen, &
Chen, 2011) and it is essential that primary health care providers have
the required education to provide care for people living with mental
disorders. Mental disorders usually have a long course. Many people
relapse because of non-adherence to medication due to lack of illness
insight or adverse effects of medication (Berge et al., 2016; von
Bormann, Robson, & Gray, 2015). Regular follow-up can improve
people's adherence to treatment and also help them to adapt socially
(Gan, Liu, Ma, & Yu, 2013). In China, few studies have focused on
training for community mental health workers; these limited studies
used traditional didactic teaching, a narrow scope of knowledge and
primarily focused on recognition of symptoms and medication man-
agement (Wang et al., 2010). One study reported success when in-
corporating hospital, community and family into the rehabilitation
planning for people with mental health problems (Zhou, Zhang, Wang,
& Wang, 2011). Currently there are no training programs involving
multidisciplinary health care providers in community mental health
education in China.
The aim of this study was to provide an interdisciplinary community
mental health training program and to evaluate the effect of the
training on staff knowledge about mental health and confidence in their
roles.
Methods
A one-group pre-test post-test design was used to test the effec-
tiveness of a multidisciplinary training program open to professionals
who were involved in provision of community mental health services. A
total of 48 participants including mental health nurses (11, 22.9%),
community nurses (16, 33.3%), community physicians (2, 4.2%),
community health care center managers (5, 10.4%), chiefs of a public
health sector service (2, 4.2%) and college faculty members supervising
students in mental health practicum experiences (12, 25.0%) responded
to the invitation to attend.
2
Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx
Table 1
Curriculum for the community mental health training workshop.
Session Content
1 Introduction and aims of the workshop
2 What is different about working in the community? (aims of community
mental Health)
3 Recovery-based model: Assessment, Planning and Treatment (APT)
4 APT (establishing a therapeutic relationship, stigma, empowerment)
5 Role of mental health clinicians in APT
6 The law and mental health (privacy, scope of practice, confidentiality)
7 Workshop: community mental health terminology
8 Case management and teamwork; referrals
9 Workshop: prevention and management of aggressive behavior
10 Mental health management structures and community resources
11 Risk assessment, mental health and emergencies
12 Dealing with emergency situations
13 Workshop: implementation and action planning
Sampling
Participants were recruited from throughout the country via hard-
copy invitations to other universities and community facilities as well
as publicizing it on the School of Nursing website. The training program
was open to all health professionals who had or would be involved in
community mental health service. Participation was voluntary.
Intervention
A three-day training workshop was designed based on the require-
ments of the Chinese Basic Public Health Service (NHFPC, 2009), the
major standards of the WHO Mental Health Action Plan 2013–2020
(WHO, 2013) and service standards and quality in mental health care
(WHO, 2012). The workshop consisted of 13 sessions on community
mental health concepts (Table 1), incorporating the main components
of several recovery models (American Occupational Therapy
Association, 2016; Government of Western Australia, 2004; Substance
Abuse and Mental Health Services Administration, 2012). The sessions
included problem solving exercises, educational handouts, lectures with
audiovisual presentations, group discussions, role play and scenario
simulations.
Measures
A questionnaire was developed to obtain basic demographic in-
formation. A researcher-designed five-point Likert-type item ques-
tionnaire was administered, before and after the training, to measure
changes in knowledge about community mental health concepts. This
questionnaire was developed based on an extensive literature review, as
well as synthesis, categorization and refinement, and 14 items closely
related to the training session were included based on expert group
discussion. For each item, the score ranged from 1 to 5, with 1 meaning
strongly disagree and 5 meaning strongly agree. The questionnaire as-
sessed knowledge of prevention of violence, rehabilitation, legal as-
pects, case management and referral. The Content Validity Index was
0.875, and the Cronbach's alpha 0.935. After the training program,
participants were asked to review their general satisfaction with the
program using a five-point scale, with a higher score indicating higher
satisfaction. The focus of these 3 items was on the curriculum, content
and teaching/learning strategies. Each session was also evaluated by
content and relevance (1 to 5) and a single item measured participants'
confidence in managing people with mental health issues (1 to 7).
Open-ended questions were used to collect participants' suggestions.
Results
The majority of participants were female (43, 89.6%). Academic
B.X. Yang et al. Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx

Table 2 study.” Participants also acknowledged that they gained considerable

Characteristics of participants (N = 48). information regarding cooperation with family and improved commu-
nication skills; especially important was coping with emergency situa-
Characteristics Frequency Percentage (%)
tions. As to the least satisfying aspects, many participants indicated
Gender Male 5 10.4 they would have liked more case studies exemplified by a participant's
Female 43 89.6 comment: “We hoped for more case studies. Perhaps more examples could
Occupation Academic faculty 12 25.0
show us different situations we might face.” There were diverse sugges-
Mental health 11 22.9
nurse tions offered according to personal interest, such as asking for more
Community nurse 16 33.3 examples and clinical cases, more videos, and less complex termi-
Community doctor 2 4.2 nology. Generally, participants agreed that the program was interesting
Manager 5 10.4 and enlightening and proved practical and useful for their future
Other 2 4.2
practice.
Community health concepts Yes 17 42.5
training No 23 57.5
Mental health training Yes 19 44.2 Discussion
No 24 55.8
Community mental health Yes 3 8.3
This study is the first Chinese study to report an educational inter-
training No 33 91.7
vention targeting health workers from different settings to promote
collaboration, and include the concept of recovery into the treatment of
mental health conditions. Globally there is a growing number of people
living with mental disorders and this constitutes a personal burden as
faculty members' years of work ranged from 0 to 26 (M = 6.73), and for well as a burden to the medical system and society. In addressing these
staff from the community and hospitals their years of work ranged from issues, WHO (2008) and WHO (2013) advocated for the integration of
0 to 24 (M = 3.75). Less than half had received community health mental health care into the primary health care setting and emphasized
training (17, 42.5%) or mental health training (19, 44.2%), and only a the requirement for effective coordination through health care institu-
few (3, 8.3%) had received community-based mental health training. tions to promote recovery and continuous care. Only 8.3% of the study
See Table 2 for participant characteristics. participants had received community mental health training and lower
There were 48 participants who returned the pre-test questionnaires scores on the pre-test knowledge items indicated a lack of knowledge
and 37 who returned the post-test questionnaires. Data from the 37 and skills. Dai and Qin (2014) surveyed community health workers in
questionnaires were analyzed. For the 14 items used to measure com- Chengdu, China, about their need for training on mental health and
munity mental health knowledge, the pre-test total score (out of 70) found the most frequently mentioned concepts were how to recognize
ranged from 20 to 68 (median = 38.00, M = 39.43, SD = 10.82) and and prevent relapse, how to protect self in the follow-up, and the skill of
the average score (out of 5) ranged from 1.43 to 4.86 (median = 2.71, case management. This is similar to findings of this study; in which
M = 2.82, SD = 0.74). The post-test total score ranged from 42 to 70 participants thought the most useful aspect was dealing with emer-
(median = 58.00, M = 58.08, SD = 6.98) and the average score (out gencies and case management. This parallels to the situation in India,
of 5) ranged from 3 to 5 (median = 4.14, M = 4.15, SD = 0.50). Since and the consequences may be inappropriate diagnosis and treatment
the score on every item was not normally distributed and the test of (Thara, Padmavati, & Srinivasan, 2004). Dai and Qin (2014) did not go
Homogeneity of Variances is significant (P < 0.05), the non-para- on to address the identified needs with training.
metric test of Wilcoxon was used. The score on every item except the Nearly a quarter of this study's participants were nursing graduates
item on empathy and the total/average score was significantly in- and their lack of knowledge about community mental health concepts
creased (z value ranged from −2.89 to 5.11, P = 0.000). Pre-test items speaks to the need to have an emphasis on basic mental health concepts
which assessed knowledge about home visits (M = 2.27, SD = 0.80, in the undergraduate curricula of all health professionals. In China, the
medium = 2), case management (M = 2.24, SD = 0.86, medium = 2) curricula of undergraduate programs of nursing and other health pro-
and follow up (M = 2.27, SD = 1.07, medium = 2) had the lowest fessionals includes a course about psychiatric and mental health but not
scores and improved considerably on the post-test assessment covered is foundational knowledge about community mental health. In
(M = 4.05, 4.14, 4.24; SD = 0.85, 0.67, 0.76; medium = 4). Following addition the delivery of content in a lecture format without clinical
the training, scores on items regarding legal issues (M = 3.78, practice is problematic. Only a few undergraduate programs meet the
SD = 0.75) and identifying the early signs of recurrence (M = 3.97, national standards regarding mental health content which stipulate 24
SD = 0.76) remained lower than 4. to 42 of class hours and 2 to 4 weeks practice (Nursing Professional
Respondents reported their confidence in managing people with Teaching Instructions Committee of Chinese Ministry of Education,
mental health issues after training was 4.78 (out of 7). Their scores on 2010). In addition the specialty of mental health is unpopular in China:
satisfaction with the program from the perspectives of course ar- a large scale study of 709 undergraduate nursing students from four
rangement (min = 2, M = 4.42, SD = 0.70), content (min = 4, medical universities reported that 334 (47.11%) students were un-
M = 4.56, SD = 0.50) and teaching/learning strategies (min = 4, willing to work in psychiatric hospitals (Liu, Wang, Yu, Pei, & He,
M = 4.69, SD = 0.47) were above 4. For each session, the scores re- 2017). Fear of violence and fear of psychotic symptoms were the major
garding content ranged from 4.00 to 4.88 and the scores for relevance two reasons.
ranged from 3.5 to 4.4. Community mental health terminology as well This training program was successful in terms of the objectives.
as case management and teamwork received the lowest relevance Participants' knowledge on community mental health care concepts
scores, < 4. Detailed information on the comparison of pre- and post- increased after the training program. A one-day traditional training
test findings is shown in Table 3. course which focused on symptoms, diagnosis and treatment of schi-
Open-ended questions were included to solicit participants' per- zophrenia and bipolar disorders on 99 community mental health staff
spectives on the training program. Comments were summarized and from Guangzhou did not produce a significant improvement of parti-
categorized into three groups: most useful aspects, least satisfying as- cipants' mental health knowledge (Li, Li, Huang, & Thornicroft, 2014).
pects and suggestions. The majority of participants highly valued the However, the same authors conducted a further study on 77 partici-
scenario simulation; as one individual stated, “The role play is very pants and 37 of them received a 14-day needs-based training program
useful. It helped me know more about how to deal with different kinds of which including traditional course, clinical practice and public health
clients with mental or psychotic disorder. I think it is useful for my further perspectives; the results indicated that the new course improved

3
B.X. Yang et al. Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx

Table 3
Pre- and post-training comparison (N = 37).

Items Pre-test Post-test D-value Z P

Mean SD Mean SD Mean SD

1. I am familiar with the concepts of community mental health 3.24 1.04 4.24 0.60 − 1.00 1.35 − 3.65 0.000
2. I know about prevention and management of violence and aggression 3.22 1.11 4.35 0.54 − 1.14 1.42 − 3.89 0.000
3. I manage at least one kind of mental health recovery skill (such as daily life skills, occupational, social skills) 3.22 1.27 4.16 0.87 − 0.95 1.67 − 2.89 0.000
4. I can be empathetic toward people with mental health disorders 4.16 0.90 4.49 0.61 − 0.32 1.05 − 1.80 0.072
5. I am familiar with legal issues related to mental health 2.70 1.08 3.78 0.75 − 1.08 1.32 − 3.87 0.000
6. I am familiar with concepts of case management and teamwork with people living with mental disorders in the 2.27 0.80 4.14 0.67 − 1.86 1.06 − 5.11 0.000
community
7. I am familiar with how to conduct a home visit with people living with mental health problems 2.24 0.86 4.05 0.85 − 1.81 1.22 − 4.68 0.000
8. I know how to deal with the emergency situations which may occur during the recovery process 2.54 0.99 4.14 0.71 − 1.59 1.21 − 4.76 0.000
9. I know how to assist people living with mental health problems to utilize community resources. 2.38 1.04 4.19 0.66 − 1.81 1.33 − 4.77 0.000
10. I know how to advise people living with mental health problems and their families in the community about 2.81 1.18 4.00 0.78 − 1.19 1.52 − 3.66 0.000
medication management
11. I know how to assist people living with mental health problems and their families in the community to identify 2.78 1.13 3.97 0.76 − 1.19 1.47 − 3.93 0.000
early signals of recurrence
12. I know how to advise family members of people living with mental health problems in the community about 2.92 1.16 4.16 0.80 − 1.24 1.40 − 4.18 0.000
safety management
13. I know how to advise family members of people living with mental health problems in the community on 2.68 1.12 4.16 0.76 − 1.49 1.37 − 4.48 0.000
improving medication adherence
14. I know how to provide follow-up care for people with mental disorders living in the community 2.27 1.07 4.24 0.76 − 1.97 1.52 − 4.65 0.000

Scoring ranges from 1 to 5; 1 = strongly disagree and 5 = strongly agree; non-parametric test of Wilcoxon was used.

community mental health staff knowledge of mental disorders and
scores was higher than control group's participants in 12 months. It
indicated that a structural design could improve knowledge level of
participants.
Because a home visit is the primary management strategy in caring
for community residents with mental health disorders, it is of great
concern that workshop participants rated their pre-test knowledge on
home visits as being very low. This could be attributed to their lack of a
mental health care background (NHFPC, 2008) and a lack of motivation
to conduct home visits on people living with mental disorders (Ma,
2016). According to their comments on their post-test questionnaires,
participants reported increased knowledge about home visits.
The style of delivery used in the training was rated the highly by
participants. In contrast to previous training conducted in China (Li
et al., 2014; Wang et al., 2010), this training program addressed the
issues of community mental health concepts based on international
guidelines and Chinese requirements, including prevention and man-
agement of aggression, legal issues, team work, home visits, and dealing
with emergency situations.
Regarding the teaching/learning strategies, participants appreciated
the focus on authentic case studies, role plays and stimulation instead of
the often-used teacher-centered rigid learning by rote (Choi &
Nieminen, 2012; Jeynes, 2008). These strategies which included psy-
chomotor and affective skills stimulated interest, and interaction and it
is anticipated that rehearsing the skills in authentic role play/simula-
tion will better at prepare them to apply their knowledge to practice
(Treloar, McMillan, & Stone, 2015). Problem-based strategies were also
highly valued by participants in this study and this approach has been
attributed to radically transforming medical education in China and
potentially leads to the development of critical reflection and acquisi-
tion of knowledge and skills (Frambach & Martimianakis, 2017).
The lack of improvement on the ability to recognize early signs of
relapse and on legal issues relating to mental health as well as the re-
quest for more role play activity may indicate a lack of clinical ex-
perience in mental health and that the course should include clinical
exposure. A training program that included clinical practice improved
clinical psychiatry knowledge of participants (Li et al., 2015). However,
a traditional training one did not improve participants' community
mental health knowledge (Li et al., 2014). Health professional educa-
tion in China has been criticized for lacking training in communication
skills (Tian & Wang, 2017; Zhang, Li, Xin, Xu, & Chan, 2016). It is
essential that interactive strategies could be utilized to promote com-
munication skills when designing curriculum or training programs.
Strengths and limitations
Both the feedback from participants and changes in knowledge
scores indicate that this intervention was successful in educating par-
ticipants about community mental health concepts. Limitations in-
cluded that transfer of learning to the workplace was not measured and
knowledge improvement was self-reported and not objectively mea-
sured.
Conclusion
This paper has reported an evaluation of an interdisciplinary com-
munity mental health training program. The key learnings were a short-
term training program with interactive strategies could improve parti-
cipants' knowledge and confidence in roles. The lack of improvement on
the ability to recognize early signs of relapse and on legal issues relating
to mental health may indicate a lack of clinical experience in mental
health and in future that supervised clinical practice with a focus on
interpersonal skills this should also be included even for senior clin-
icians.
Acknowledgments
Sincere thanks are given to Dr. Sharon R. Redding (EdD, RN, CNE)
and Dr. Joyce Fitzpatrick (PhD, MBA, RN, FAAN) for assistance in the
preparation of this manuscript. We appreciate the grant support from
National Natural Science Foundation of China (No. 71503192) and
Wuhan University HOPE School of Nursing Independent Research Fund
(No. JSZD 2016006).
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