Strengthening rehabilitation care for psychiatric inpatients in Iraq

Author(s) Denis Caharel1, Anne Laure Monod2, Khouloud Hashim3, Naama Shlaba Humaidi 4, Maïté Pahud 5, Renato Oliveira e Souza6, Pierre Bastin7
Affiliation(s) 1department of psychiatry, Hôpitaux universitaires de Geneve, Genève, Switzerland, 2Department of Psychiatry, Hôpitaux universitaires de Genève, Genève, Switzerland, 3Al Rashad Hospital, Al Rashad Hospital, Baghdad, Iraq, 4Al Rashad Hospital, Al Rashad Hospital, Baghdad, Iraq, 5Health unit, ICRC, Genève, Switzerland, 6 Health Unit, Assistance Division ICRC, ICRC, Genève, Switzerland, 7 Health Unit, Assistance Division ICRC, ICRC, Genève, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Clinical Practice and Hospitals
Summary Al Rashad hospital is the only psychiatric hospital in Iraq. It is supported by the International Commitee of the Red Cross. The University Hospitals of Geneva assisted in strengthening occupational workshops and develop rehabilitation therapy. An assesment of nurses' knowledge, attitudes and practices was carried. Psychiatric nurses were trained in occupational and rehabilitation therapy using interactive methods. From 2011 to 2013, 60 nurses were trained. There was a four-fold increase in the number of patients particpating in rehabilitation therapy. We demonstrated a successful partnership between hospitals in strengthening rehabilitation care for psychiatric inpatients in Iraq.
Background Al Rashad hospital is the only psychiatric hospital in Iraq. It is a 1375 bed hospital located in Baghdad near Sadr city, ten kilometers away from the city centre. About 90% of patients, mostly males, suffer from chronic schizophrenia and are long-term patients residing at the hospital. Due to stigmatization of psychiatric patients, most of patients are admitted upon family's request and discharge from hospital is usually difficult afterwards. The hospital staff comprises of 10 psychiatrists and around 130 nurses, some of them working as rehabilitation staff. Training on psychiatric care or occupational therapy for nurses does not exist. Al Rashad hospital has been supported by the International Commitee of the Red Cross (ICRC) since 1999. The ICRC has performed important construction work in order to increase patient capacity and to improve living conditions. The organization donated material for rehabilitation workshops and appointed a part-time social worker to assist hospital staff. In December 2010, Al Rashad hospital, through the ICRC, requested support from the Department of Psychiatry at the University Hospitals of Geneva (HUG) to access ongoing rehabilitation activities for psychiatric inpatients and to provide directions on further development of rehabilitation care.
Objectives The main objective was to improve renabilitation care including occupational therapy and to allow discharge of psychiatric inpatients and a return to social and professional life.
In December 2011, Al Rashad psychiatric hospital, the ICR and the HUG agreed on the following objectives:
- to measure patient's needs in terms of nursing care;
- to define rehabilitation therapy needs and objectives;
- to develop a training programme suitable to the local context and adapted to the theoretical and practical needs of rehabilitation nurses;
- to conduct training sessions for nurses from all wards;
-to provide ongoing supervision to rehabilitation nurses during workshops with patients.
A sub-objective was to develop family approaches to decrease stigma and facilitate discharge of patients from hospital and return to family life.
Methodology The first mission included an assessment of nurses' knowledge, attitudes and practices about rehabilitation therapy. Interviews and discussions with ICRC and Al Rashad professionals were conducted by the HUG psychiatric expert team made up of an occupational therapist and a specialized psychiatric nurse. Visits of hospital wards and rehabilitation workshops to observe the daily reality of inpatients were also made.
Following this first visit, the training programme was developed in Geneva by the HUG team with the help of two experts in psychiatric training for nurses. Five one-week modules were defined on observational techniques, psychiatric signs and symptoms, attachment theory, Maslow's pyramid, communication, occupational therapy, techniques to conduct individual and group work with patients and their families, and multidisciplinary work. To cover theoretical and practical aspects, interactive methods were used such as presentation of clinical cases by trainees, role games, patients' interviews, occupational therapy exercises and group therapy. Trainees had the opportunity to watch movies about how rehabilitation care is practiced in the HUG and examples of a schizophrenic patient's interview. The movies were then extensively discussed to highlight similarities and discrepancies in psychiatric rehabilitation in Baghdad and Geneva.
The five modules were delivered through a period of eighteen months. In between modules, the trainees were asked to deliver a report on how they introduced techniques learnt into their daily practice and to present it to their peers. Each training module was evaluated by the trainees and comments were integrated to improve the next module.
Translation between Arabic and French was conducted by an Iraqi medical doctor.
In addition, an assessment of nursing care provided for daily life activities in the hospital, on the fields of hygiene, clothing and meals, was conducted by the ICRC health team working in Baghdad in August 2012.
Results From April 2012 to November 2013, 60 nurses of Al Rashad hospital were trained on psychiatric rehabilitation and nursing care, 10 of them attending all five one-week modules. This lead to about a four-fold increase in the number of patients participating in occupational therapy, from an estimated 130 patients in 2011 to 570 in 2013.
Most of the nurses were satisfied or very satisfied with all training modules. During the modules, the trainees requested more practical exercises as well as guidelines for psychiatric care and occupational therapy. At the end of the training programme, all nurses could quote several techniques used in their daily practice.
Improvement in the quality of nurses' assignments and reports was also observed: psychiatric techniques, occupational therapy, empathy for patients and families, multidisciplinary work and involvement of nurses improved module after module.
The audit demonstrated good improvement on basic nursing care, hygiene, clothes and meals in most of the wards. Al Rashad health authorities and the ICRC health team discussed ways of improvement, including human and material resources, for the wards where nursing care was still inadequate.
Conclusion We demonstrated a successful partnership between Al Raschad hospital, the HUG and the ICRC in strengthening rehabilitation care for psychiatric inpatients in Iraq. The HUG training team brought their expertise and experience in rehabilitation care while the involvement of the ICRC was key in delivering continuous support on the ground and approaching health authorities.
This collaboration responded to changes in psychiatric care requested by Al Rashad hospital authorities and staff: the improved participation of patients in rehabilitation and occupational workshops to eventually facilitate the patients' return in social life.
Discussions and exchanges between trainees and trainers on differences in context, culture, experience of rehabilitation care and psychiatric knowledge were the keys to success. Teaching methods and training contents were adjusted after each module following evaluation by trainees.
Further work is now needed to allow patient's rehabilitation outside the hospital.

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