Lived experiences of Ghanaian community psychiatric nurses resilience strategies in combating stigma: an interpretive phenomenology

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A semi-structured interview guide (Appendix I) with two sections was used for data collection: Section A and Section B.

The interviews were designed to ensure privacy and prevent external influences, thereby encouraging participants to provide in-depth and honest responses. All interviews were conducted in English, eliminating the need for an interpreter.

With the consent of the participants, the interviews were tape-recorded to ensure accuracy and completeness of the data. These recordings were later transcribed manually. Additionally, field notes were taken during the interviews to capture non-verbal cues and other observations that could provide further context to the participants’ responses.

Almost all participants mentioned that ignoring and avoiding undesirable attitudes helped them cope with stigma. This approach allowed them to continue their work without being overwhelmed by negative perceptions.

Yaw shared: “We just ignore it because it has become normal. We ignore it and just live our lives. For me, I ignore it. I don’t know the technical name for it. I just ignore it. I behave as if I have not seen it or if I have not heard.”

Yaw’s narrative highlights a sense of resignation and adaptation. By normalizing the stigma, Yaw and his colleagues have developed a thick skin, allowing them to focus on their duties without being constantly affected by negative attitudes. This coping mechanism, while not addressing the root cause of stigma, provides immediate relief and helps maintain their mental well-being.

Adwoa expressed: “I used to be worried about it earlier on, but now we ignore if there is a statement.”

Adwoa’s journey from worry to indifference illustrates a personal evolution in coping strategies. Initially, the stigma caused significant distress, but over time, Adwoa learned to detach emotionally from the negative comments. This shift not only reduced her anxiety but also empowered her to continue her work with a clearer mind.

Yaa noted: “Personally, I am that person I easily look over things. Therefore, for me, I just overlooked.”

Yaa’s ability to overlook negative attitudes reflects a natural resilience. Her narrative suggests that some individuals may have an inherent capacity to brush off negativity, which can be a valuable trait in high-stress environments. This resilience allows Yaa to maintain her focus and dedication to her work.

Mansah highlighted: “You know sometimes you don’t have to be thinking of anything. If you say you will think of everything you will go mad actually, I basically avoid and ignore them. It’s like I’ve not heard anything. I just ignore as if nothing has happened.”

Mansah’s narrative underscores the mental toll that constant negativity can take. By choosing to avoid and ignore, Mansah protects her mental health, preventing herself from becoming overwhelmed. This strategy is a form of self-preservation, allowing her to continue her work without succumbing to the pressures of stigma.

Afia mentioned: “I ignore, that is how I am. I laugh and ignore.”

Afia’s approach combines humor with avoidance. By laughing off negative comments, she not only deflects the stigma but also maintains a positive outlook. This combination of humor and indifference can be a powerful tool in mitigating the impact of negative attitudes.

Akua added: “There was a time I stopped going to some units because I realized if those people were there, I would not be able to control myself. Therefore, I won’t even go at all. I ignore especially when you have done it more than three (3) times. I will ignore you.”

Akua’s narrative reveals a proactive approach to avoiding stigma. By choosing not to engage with certain environments, she protects herself from potential triggers. This strategy highlights the importance of setting boundaries and recognizing one’s limits in managing mental health.

Rhoda underscored: “What I normally do is I overlook it. We overlook these things. I ignore them and then I think they are also ignorant about certain things, so I even pity them. Hmm, I ignore and avoid them in the best way I can.”

Rhoda’s narrative adds a layer of empathy to the coping mechanism. By recognizing the ignorance behind the stigma, she is able to show compassion rather than resent those who perpetuate it. This perspective not only helps her cope but also fosters a sense of compassion, reducing the emotional burden of negative attitudes.

Some participants chose to confront the sources of stigma directly, either by addressing the issue on the spot or by reporting it to higher authorities.

Yaw’s willingness to confront authority figures demonstrates courage and a desire for change. By addressing the issue directly, he not only stands up for himself but also advocates for his colleagues. This proactive approach can lead to systemic changes and improved working conditions.

Yaa stressed: “Oh we are coping, it’s like we are getting used to it, and we are trying to manage the little resources that we have. When we think there is the need to talk about it, we delegate someone to go and talk to our director about it. So, we are just managing.”

Yaa’s narrative reflects a collective approach to confrontation. By delegating representatives to address issues, the group ensures that their concerns are heard while maintaining a united front. This strategy fosters a sense of solidarity and shared responsibility among the team.

Rhoda mentioned: “Actually, we go to the top, and people complain, and I think they are taking note of it. Sometimes I will tell you straight I don’t like that.”

Rhoda’s directness in addressing issues highlights the importance of clear communication. By expressing her dissatisfaction openly, she sets boundaries and ensures that her concerns are acknowledged. This approach can lead to immediate resolutions and a more respectful work environment.

Suzzy added: “Yea we were complaining and when we went to the authorities, the DDNS and the rest to complain to, that we don’t like the way we were being left out. Like workshops, they forget about us. So sometimes we complain and confront the issues.”

Suzzy’s narrative emphasizes the importance of advocacy and persistence. By repeatedly bringing their concerns to the authorities, she and her colleagues work towards ensuring that their needs are met. This ongoing effort can lead to gradual improvements and greater inclusion in professional development opportunities.

Discussing issues among themselves helped participants cope with unpleasant experiences. Sharing their anxieties and advising each other provided emotional support.

Rose’s narrative highlights the therapeutic value of group discussions. By creating a safe space to share their experiences, the participants can release pent-up emotions and gain new perspectives. This collective support system fosters a sense of community and mutual understanding.

Nancy mentioned: “Hmmm, we meet as a unit, and we discuss any unpleasant issues after we are done with our reviews.”

Nancy’s approach to regular meetings ensures that issues are addressed promptly. By incorporating discussions into their routine, the team can continuously support each other and address any emerging concerns. This proactive strategy helps maintain a positive and cohesive work environment.

Maria added: “As the unit in charge, I try to organize a monthly discussion where each and every one brings out her problems, including humiliating and discriminating issues, for us to discuss.”

Maria’s leadership in organizing monthly discussions demonstrates a commitment to her team’s well-being. By encouraging open dialogue, she fosters a culture of transparency and support. This regular check-in helps identify and address issues before they escalate, promoting a healthier work environment.

Many participants believed that educating the public about community psychiatric nursing helped address stigma. By providing information, they aimed to correct misconceptions and reduce negative attitudes.

Adwoa stated: “We addressed the statements made; educate them on what we do. So that is how we normally manage our stigma, because they don’t truly know or understand what they are saying. Therefore, we also educate them on what we do.”

Adwoa’s narrative underscores the power of education in combating stigma. By informing the public about their work, CPNs can challenge misconceptions and foster greater understanding. This proactive approach not only reduces stigma but also promotes respect and appreciation for their profession.

Mansah mentioned: “The public does not truly know what community psychiatric nursing truly entails. We leave it to spiritual something. We don’t have that education. If education goes down well, they will understand it.”

Mansah’s narrative highlights the gap in public knowledge about community psychiatric nursing. By addressing this gap through education, CPNs can demystify their work and reduce the stigma associated with it. This long-term strategy aims to create a more informed and supportive community.

Almost all participants said that what helped them deal with stigma was ignoring and avoiding the undesirable attitudes of people shown towards them. They did this to prevent themselves from being hurt. This approach aligns with the research of Yanos et al. [15], who discussed individuals whose coping mechanism involved avoiding and ignoring people who teased and ridiculed them. They mentioned that others manage stigma by completely ignoring the source of stigma and withdrawing to avoid being stigmatized.

However, Treichler and Lucksted [29] argued that avoiding and ignoring the source of stigma could be a result of self-stigma. Another study by Yanos, DeLuca, Roe, and Lysaker [15] reported that avoidant coping and neutral coping were strategies adopted by some people to cope with mental illness stigma. In this study, participants used neutral coping strategies such as ignoring the stressor, relaxation techniques, and religious activities. The authors also reported that anger, avoidance, violence, and sleeping were used for avoidant coping.

Ignoring and avoiding stigma can be seen as a double-edged sword. While it provides immediate relief and helps individuals maintain their mental well-being, it does not address the root cause of stigma. This coping mechanism can lead to a sense of isolation and may prevent individuals from seeking support or advocating for change.

From a psychological standpoint, ignoring and avoiding stigma can be viewed as a form of emotional regulation. This strategy helps individuals manage their emotional responses to negative stimuli, reducing stress and anxiety. However, it may also contribute to feelings of helplessness and resignation if individuals feel they have no control over the situation.

On a societal level, widespread use of this coping mechanism can perpetuate stigma by allowing negative attitudes to go unchallenged. It highlights the need for broader societal change and collective efforts to educate and shift public perceptions.

The second subtheme of the main theme, ‘resilience strategies’, was confrontation. Some participants objectively handled matters right there and then when ridiculed or teased. Similarly, according to Sercu et al. [17], confronting stigma was a significant and peculiar course of action nurses took to enable them to work in mental health care institutions.

Confrontation as a coping mechanism can be empowering for individuals, as it allows them to assert their rights and challenge negative attitudes directly. This approach can lead to immediate resolutions and foster a sense of agency and control.

Confrontation can be seen as a form of assertiveness training, where individuals learn to stand up for themselves and communicate their needs effectively. This strategy can boost self-esteem and reduce feelings of powerlessness.

On a societal level, confrontation can drive change by challenging discriminatory practices and attitudes. It can raise awareness and prompt institutions to address issues of stigma and discrimination more proactively.

Some participants reported discussing issues among themselves, such as some of the unpleasant things they go through and advising each other truly helped. They found the ability to move on anytime they discussed stigma issues among themselves and encouraged each other. This agreed with the findings of Xu et al. [30], who reported that one is able to withstand stigmatization because of group interactions. They also said it helps in dealing with stigmatization. Echezarraga, Las Hayas, López de Arroyabe, and Jones [31] discovered that people cope with stigma through social support groups such as friends, family members, and colleagues. Supportive peer discussions provide a platform for mutual support and shared experiences. They help individuals feel less isolated and more understood, fostering a sense of community and belonging.

From a psychological perspective, the discussions can serve as a form of social support, which is crucial for mental health. Sharing experiences and receiving validation from peers can reduce stress and enhance coping abilities.

On a societal level, group discussions can contribute to a culture of openness and support. They can also serve as a foundation for collective advocacy efforts, where individuals come together to address stigma and promote change.

Most participants believed that they were treated badly because the public did not understand community psychiatric nursing and therefore used education as a coping mechanism to address any unhealthy comments. This finding is consistent with that of Corrigan, Morris, Michaels, Rafacz, and Rüsch [32], who reported that many strategies have been used to combat public stigma, prejudice, and discrimination, which are endorsed by the general public. Overall, strategies that included the education of the public about mental illness and contact with people who have mental illness were effective. Echezarraga et al. [31] also mentioned that people cope through education.

Education as a coping mechanism empowers individuals to challenge misconceptions and promote understanding. By providing accurate information, they can reduce stigma and foster a more supportive environment.

From a psychological standpoint, education can be seen as a form of cognitive restructuring, where individuals challenge and change negative beliefs and attitudes. This strategy can enhance self-efficacy and promote a more positive self-image.

On a societal level, education can drive long-term change by shifting public perceptions and reducing stigma. It can also promote inclusivity and acceptance, creating a more supportive and understanding community.

In examining the resilience strategies of community psychiatric nurses in Ghana, it is essential to consider findings from international studies. For instance, research conducted in the United States and Turkey has shown that psychiatric nurses often employ strategies such as avoidance, confrontation, and public education to manage stigma [10, 11]. These studies highlight the universal challenges faced by mental health professionals and the diverse strategies they use to cope with stigma. By comparing these findings with those from Ghana, we can gain a deeper understanding of how cultural contexts influence resilience strategies.

Our study revealed that community psychiatric nurses in Ghana primarily rely on community support and public education to combat stigma. This contrasts with findings from studies in Western countries, where nurses often use more individualistic coping strategies, such as personal therapy and professional support groups [10, 11]. These differences underscore the importance of cultural context in shaping resilience strategies. In Ghana, the strong sense of community and collective responsibility plays a crucial role in how nurses address stigma.

The cultural and social context in Ghana significantly impacts the resilience strategies of community psychiatric nurses. In Ghanaian society, mental illness is often stigmatized, leading to social isolation and discrimination. Our findings indicate that nurses cope with this stigma by engaging in public education and community outreach, aiming to change societal attitudes and reduce stigma [10, 11]. Our findings indicate that nurses cope with this stigma by engaging in public education and community outreach, aiming to change societal attitudes and reduce stigma [10, 11]. This approach is deeply rooted in the cultural values of communal support and collective action, which are prevalent in Ghanaian society. For example, one of the nurses we interviewed shared a powerful example of how she uses public education to combat stigma. She organizes community meetings where she educates the public about mental health and the importance of supporting individuals with mental illness. This strategy not only helps to reduce stigma but also fosters a sense of community and mutual support [10, 11]. Such examples illustrate the practical application of coping mechanisms within the cultural context of Ghana.

Considering the cultural context in our analysis provides valuable insights into the coping mechanisms of community psychiatric nurses in Ghana. It highlights the need for culturally sensitive approaches to addressing stigma and supporting mental health professionals. By understanding and integrating these cultural factors, we can develop more effective strategies to combat stigma and improve mental health care globally [10, 11].

The study has limitations that should be acknowledged. Firstly, the relatively small sample size, drawn from only three community psychiatric units in the Accra metropolis, may not fully capture the diverse experiences of community psychiatric nurses (CPNs) across different settings. This urban focus limits the applicability of the findings to other regions or rural contexts.

Additionally, the investigators’ background in Community Mental Health Nursing may have influenced the research process, despite efforts to mitigate these effects. Furthermore, the gender representation in the sample was limited, with only one male CPN participating, which may affect the generalizability of the insights gained.