Understanding Thai Community Nurses’ Experiences of Caring for Psychiatric Patients in Primary Care Units: A Phenomenological Study

INTRODUCTION

Mental illness constitutes a pressing global health concern, impacting at least ten percent of the world’s population at any given time. ¹ Its prevalence continues to rise, presenting substantial challenges to healthcare systems worldwide, including Thailand. ² Over the last two decades, a notable shift has been towards community-based care to address mental health issues. This approach aims at providing robust support within the home environment, reducing the necessity for hospitalization and promoting early discharge when appropriate. ³ In this context, recovery management becomes crucial, emphasizing active participation in ongoing care to control the remission of symptoms, prevent a recurrence, and minimize the risk of re-admittance. These are the primary goals. Rehabilitation also underscores the importance of enhancing hope, dignity, meaning, and personal responsibility among patients, families, and communities. ⁴ The ultimate objective is to empower individuals with mental illness to achieve a fulfilling life beyond the constraints imposed by their mental health conditions. ⁵

In several developed countries, the expansion of psychiatric nursing roles has been pivotal in managing mental illness at the community level. Trained psychiatric nurses, commonly known as ‘community psychiatric nurses’ (CPNs), play a crucial role in providing ongoing care to patients who have undergone treatment and have been discharged. ⁶ Their mission is to ensure adherence to treatment regimens, thereby reducing the risk of relapses. ⁷ CPNs effectively bring the hospital to the patient’s home, enhancing healthcare accessibility. ⁸ They engage in inpatient tracing, home visits, and regular patient assessments. Additionally, CPNs are liaisons between patients and various healthcare facilities, ensuring effective communication of patients’ needs. ⁶ Beyond these responsibilities, CPNs play a critical role in mental health education, providing valuable insights to the general public through health talks at outpatient departments, schools, and community organizations. Their services extend to family members, friends, and anyone who interacts with individuals with mental illness. ⁸ Unfortunately, such CPNs are not available in Thailand; this responsibility falls on community nurses; these limitations represent gaps in community mental health and psychiatric care that require improvement.

In Thailand, individuals grappling with psychiatric conditions often endure the weight of illnesses. The mental health policies in the country accentuate curtailing hospitalization durations, foregrounding community integration, and facilitating the reunification of patients with their families whenever feasible. ² The framework of mental health care delivery at the community level in Thailand has been transforming to catering to the multifaceted needs of the populace and fostering accessibility and inclusivity. Several pivotal facets characterize mental health care delivery at the community level in Thailand, notably establishing mental health centers within community hospitals to dispense mental health services at the grassroots level. These centers offer a spectrum of services encompassing assessment, counseling, medication management, and psychosocial support to enhance accessibility to mental health care for individuals encountering impediments in accessing services within conventional hospital settings. ^{2 , 7} Additionally, concerted efforts have been made to amalgamate mental health services with primary health care in Thailand. This fusion ensures the availability of mental health care alongside other healthcare provisions, thereby augmenting accessibility for individuals seeking assistance for mental health issues. Primary care providers are equipped with the requisite training to conduct screenings for prevalent mental health conditions and administer essential interventions, with established referral pathways for specialized care when warranted. ^{2 , 6} Healthcare delivery at the community level in Thailand frequently involves outreach initiatives and community engagement endeavors. These endeavors are geared towards heightening awareness regarding mental health matters, mitigating stigma, and fostering help-seeking behavior. Outreach endeavors may encompass educational workshops, public awareness campaigns, and community-oriented events promoting and preventing mental health issues. ^{2 , 6 , 7}

However, the development of community-based mental health management in Thailand is still underway, and there is a notable deficiency in specialized expertise. ⁹ As a consequence, the responsibility for delivering psychiatric care to prevent relapse and foster positive change predominantly rests on CNs within the primary care system. These CNs hold bachelor’s degrees but often lack formal training in psychiatric care. However, they play a crucial role in providing ongoing mental health support, ^{9 - 11} focusing on tasks such as supporting patients in adhering to medication regimens, preventing substance abuse, managing life stressors, and promoting mental well-being. ^{9 - 11} These CNs may require support from specialized psychiatric nurses in hospitals. ¹⁰ Unfortunately, the current state of affairs limits the scope of psychosocial interventions to outpatient facilities near major urban centers, leaving a significant portion of the population without access to essential mental health services. ^{2 , 12} This lack of engagement from psychiatric patients within the community results in untreated or inadequately treated mental health conditions. ¹¹ The repercussions of such neglect can be severe, leading to prolonged suffering, restricted choices, and diminished self-esteem, with potentially tragic outcomes such as suicide. ¹³ Addressing these challenges requires a collaborative effort involving various stakeholders, including health volunteers, neighbors, community leaders, community career development groups, community welfare states, and psychiatric care teams. These collaborative efforts should be tailored to each patient’s unique circumstances and context, ^{11 - 12} aiming to improve mental health outcomes and reduce the negative consequences associated with untreated or inadequately treated conditions. ^{2 , 12}

CNs navigate a delicate equilibrium between expectations and limitations, giving rise to conflicts, frustration, and personal challenges. ¹⁰ These conflicts extend beyond individual struggles, impacting patients, families, communities, and healthcare services within the primary care system. ¹¹ Despite the critical nature of their role, the literature on CNs in the context of mental health services within the primary care system in Thailand is notably sparse. ^{10 , 11 , 14} To address this gap, especially in the care of psychiatric patients in the community, including those at risk of recurrence and violence under non-specialist management, there is a pressing need to formulate practical guidelines in situations where specialists’ resources are limited. ¹⁰ Understanding CNs’ experiences is crucial for uncovering the roots of problems and identifying specific needs. This understanding forms the basis for an informed policy decision to enhance the effectiveness of community-based mental health care. ^{2 , 10} Consequently, this study seeks to explore the lived experiences of CNs in providing psychiatric care within the primary care system in southern Thailand.

MATERIALS AND METHODS

The current qualitative study was performed based on the phenomenological approach. The CNs in providing psychiatric care across primary care units (PCUs) were purposefully selected based on the specific inclusion criteria: having a minimum of one year of experience working in PCUs in southern provinces of Thailand, including Nakhon Si Thammarat, Krabi, Phangnga, and Chumporn; having at least one year of experience in providing care to psychiatric patients, and being willing to participate in interviews. The sampling procedure was conducted between March and December 2019, during which nine individuals at nine primary care units were approached for potential inclusion in the study.

This study utilized a semi-structured approach, conducting individual in-depth interviews with participants to glean comprehensive insights into their roles, responsibilities, and experiences in psychiatric care provision in community settings. The interview protocol encompassed a series of carefully crafted questions: “Kindly share your experiences on psychiatric care in the community settings, elucidating your actions, interactions with clients and their families encountered with challenges, successes, and any barriers.” Supplementary questions delved into the emotional dimensions of participants’ experiences, their perceptions of psychiatric care, their perspectives on patients, their professional roles, as well as their expectations and support needs concerning the delivery of psychiatric care.

The interview sessions, which lasted between 60 to 90 minutes per participant, were conducted with the prior consent of participants for audio recording. Two interviewers were present: the first author (SA), with a background in psychiatric nursing, and the second author (NN), an expert in community nursing. The first author conducted individual interviews with all participants, concentrating on posing questions and steering the conversation. Concurrently, the second author meticulously recorded detailed notes and observed non-verbal cues. This methodological approach is designed to yield a richer and more comprehensive data set. The interviews were held in designated rooms within the PCUs to guarantee privacy and confidentiality. The structured format of each interview began with rapport-building activities, transitioned into casual conversation, and then progressed to open-ended questions with additional probing as necessary. Participants were actively encouraged to articulate their experiences related to the focus of the study. Following the interviews, the interviewers engaged in collaborative debriefing sessions. Here, they reflected on their experiences, identified emerging biases, and maintained awareness of them. This process ensured that one interviewer’s opinions did not influence the other, thus enhancing the integrity and accuracy of the data collected.

Simultaneous data collection and analysis were undertaken, with themes emerging from the lived experiences of CNs providing psychiatric care in primary care settings. The interviews reached a point of data saturation, where further data collection was deemed unlikely to yield additional valuable insights. Consequently, data analysis was conducted, identifying the critical themes that encapsulated the essence of participants’ experiences in delivering psychiatric care in community settings.

Data analysis followed the seven steps outlined in Colaizzi’s phenomenological method: ^{15 - 17} (1) Verbatim transcriptions of participants’ responses were generated, with validation and accuracy ensured through repeated listening to audio recordings and thorough script readings. (2) Significant statements directly pertinent to the research phenomenon were extracted from the transcripts. (3) Formulated meanings, closely aligned with the phenomena of participants’ experiences, were developed after careful consideration of the significant statements. (4) Formulated meanings were categorized into themes based on commonalities. (5) A comprehensive description of the phenomenon was crafted, encompassing all the themes identified in step 4. Furthermore, (6) rigorous discussions occurred between the researchers, with any disagreements addressed until a consensus was reached, and (7) verification was ensured through methods: peer-briefing and presenting the final draft of the results to the participants for their confirmation or modification of the study analysis of outcomes. The qualitative data analysis in this study was conducted manually using these steps. The researchers actively acknowledged their perspectives, experiences, and biases throughout this process.

Trustworthiness in this study was ensured through a rigorous process involving cross-validation by two interviewers’ checking, peer checking, and sustained engagement. ¹⁸ Their checking involved soliciting participant feedback regarding the conclusions drawn from their initial interviews conducted independently by each interviewer, with a deliberate effort to prevent mutual influence on their opinions. To ensure the dependability of the findings, three psychiatric nurses, specialists in the field, conducted peer checking. Prolonged engagement in the research field enabled the authors to build trust with participants and develop a deeper understanding of the research context. This immersion was critical to ensure the collected data was relevant and sufficient to achieve the study objectives. Maximum variation in sampling was further employed to enhance the confirmability and credibility of the data. Researchers validated the depth and authenticity of the content by recognizing diverse and novel data. The analysis was concluded after identifying several themes that effectively captured the CNs’ experiences providing psychiatric care in primary care settings.

This study obtained approval from the Human Research Ethics Committee of Walailak University (Approval No. WUEC-19-028-01). Before obtaining written consent, participants were thoroughly informed about the purpose and nature of the research. They were explicitly assured of their right to withdraw consent at any study stage. Each participant was assigned a unique identification number to maintain anonymity and privacy.

RESULTS

The study included nine CNs, all females, with an average age of 41.3±8.46 years (ranging from 30 to 55). Their education background revealed that seven held Bachelor’s degrees, while 2 held Master’s degrees. Three participants were single, and six were married. They had an average working experience in the PCUs of 12.6±7.09 years, from 3 to 25 years, as presented in Table 1.

The study findings elucidated three overarching themes grounded in the participants’ experience: “Confronting role expansion in long-term psychiatric care responsibilities,” “Insecurity in role ambiguity,” and “Duty of supportive caring for marginalized people.” Table 2 comprehensively summarizes the emerged themes and their respective subthemes.

1. Confronting Role Expansion in Long-term Psychiatric Care Responsibilities

1. a. Necessity of the expansion of CNs’ role

The Mental Health Department (MHD) advocates for minimizing the duration of psychiatric patients’ hospital stays, emphasizing their swift reintegration into community settings. This strategic approach combines a concerted endeavor to reduce relapse and readmission rates. In this transformative paradigm, CNs are pivotal in ensuring the seamless provision of psychiatric care. Consequently, the responsibilities entrusted to CNs transcend the boundaries of psychiatric care, encompassing the holistic management of chronic illnesses within the community.

“This policy not only limits hospital admissions for psychiatric patients but also places the responsibility for the quality of ongoing care for psychiatric patients and individuals suffering from various chronic conditions squarely in the hands of CNs. The challenge is formidable, but it is a task that necessitates our unwavering commitment.” (P4)

1. b. Pressing Imperatives for Long-term Psychiatric Care

CNs identify the manifestation of psychotic symptoms, such as hallucinations and delusions in patients. These symptoms often arise from a lack of treatment, substance abuse, severe stress, and inconsistent medication adherence. Such untreated symptoms not only directly affect the patients but also pose significant risks to themselves and others, potentially leading to self-harm or violence towards family members or neighbors. This situation represents a considerable threat to the safety and well-being of the broader community. Consequently, it is imperative to provide continuous long-term care to ensure psychiatric patients receive and consistently adhere to their medication regimens to manage their symptoms effectively.

“I think patients with psychiatric problems need to be cared for and treated continuously because most of them lack treatment, many use substances, are stimulated with stress, and do not take their medicine consistently. Sometimes they cannot control themselves and may hurt themselves or harm others, such as abusing or acting aggressively towards family members and others in the community.” (P1)

2. Insecurity in Role Ambiguity

2.a. Feeling Insecure

Each CN grapples with the perception that psychiatry is a complex field for which they lack formal training, leading to uncertainty about their ability to provide adequate care. Their efforts primarily focus on conducting home visits to empower patients and caregivers, intending to reduce readmissions, suicides, homicides, and related concerns. Despite adhering to standardized guidelines and collaborating with welfare services and support networks, CNs recognize the limitations of conventional treatments in addressing the profound, intricate problems that patients face. Patients often require deep psychotherapy and a nuanced understanding of their complex issues, which instills anxiety in CNs about the potential for inadvertently causing harm.

“We visit patients, following established guidelines, to reduce relapses, readmissions, suicides, and homicides. We advise and empower them to adhere to medications, mitigate drug side effects, steer clear of narcotics, alleviate stress, and engage with welfare and support systems. However, I have realized that these measures may not suffice for patients. They require healing on a profound level, addressing the deep-seated complexities in their lives. These concerns make me insecure, as I fear that my words may inadvertently harm patients.” (P7)

2. b. Role Ambiguity of Caring

CNs within PCUs undertake various psychiatric care duties, including medication management, support to prevent substance abuse, stress management to avert crises such as suicide and homicide, and promoting mental well-being to minimize readmission. Participants commonly perceive psychiatric patients as requiring specialized care for comprehensive healing, especially during crises involving aggression, homicide, and suicide. This highlights the need for tailored psychiatric interventions that address the complex needs of these patients in high-risk situations. Holding bachelor’s degrees and attending skill enhancement workshops, CNs acknowledge the limitations of their capabilities. Even with mentorship from community hospitals and collaboration with healthcare teams from tertiary care centers, CNs experience suffering, uncertainty, and an inherent discomfort in dealing with patients and their families.

“Specialists, not CNs like me, should undertake this role, as we are not adequately equipped for these complex issues. This role ambiguity causes stress, self-doubt, and confusion. In crises, the lack of clear roles and predictability further hampers our effectiveness. Patients and their families need specialized treatments for true healing and mental improvement, but these are beyond our reach.” (P4)

CNs highlight fairness concerns, particularly for those lacking specialized training, and note the time-consuming nature of psychotherapy, which adds to their already heavy workloads. Ambiguity in assigned duties and inadequate training, expertise, and care time compound caregiving uncertainties.

“It feels unjust, both for me and my patients, because I lack the specialized training of a psychiatric nurse. I attempt to provide therapy, but I find myself incapable. Moreover, mental health care demands a significant amount of time. I must juggle responsibilities for patients in the community with various medical conditions. The heavy workload makes it challenging to dedicate the time required for comprehensive care.” (P9)

3. Duty of Supportive Caring for Marginalized People

3.a. Caring for Marginalized and Stigmatized Patients

The participants gained a profound understanding of the prolonged suffering endured by psychiatric patients and their families, further compounded by societal insults and stigma. This often led to their marginalization and exclusion, burdening them with labels and perceptions that undermined their perceived competence. Despite these challenges, patients and their families held onto hope, valuing the kindness and companionship extended by nurses. They expressed deep gratitude for the nurses’ efforts to collaborate with welfare organizations and mobilize local resources, which significantly improved their quality of life and instilled newfound confidence to live in a more supportive environment.

“Psychiatric patients, relegated to the fringes of society, endure long-lasting affliction, often amid scorn and societal stigma. They bear the weight of labels and are frequently underestimated in their abilities. However, these patients and their families harbor hope, value the sense of being understood and hold an immense appreciation for the camaraderie that nurses extend. Notably, they express profound gratitude for the nurses’ initiatives in partnering with welfare organizations and rallying community resources to improve their lives, rekindling their confidence to live within a more nurturing framework.” (As one nurse shared, her eyes glistened with a smile and tears).” (P8)

3. b. A Duty to Provide Supportive Care

CNs grapple with the realization that patients and their families rely heavily on primary healthcare personnel, especially considering the limited specialized care available within their communities. They acknowledge that, within the community, they are often the only CNs dedicated to providing close and comprehensive care to psychiatric patients. Despite recognizing their limitations in offering complex services, CNs wholeheartedly commit to addressing patients’ illnesses within the community. Their dedication stems from a profound desire to witness the recovery of psychiatric patients and to see them live with dignity and normalcy, as befits all human beings.

“I have realized that only CNs can truly assist these patients and their families. Considering the constraints associated with specialized care, no other healthcare providers are working as closely with these individuals. When psychiatric patients are relegated to obscurity and abandonment, it underscores the imperative for help. As CNs, we must extend our assistance to these patients to the fullest extent possible, for it is our inherent duty as humans to lend a helping hand.” (P1)

DISCUSSION

This study expressed the lived experiences of Thai CNs of caring for psychiatric patients in PCUs when confronted with role expansion, insecurity in role ambiguity, and the duty of supportive caring for marginalized people. The findings of this study shed light on the indispensable role that nurses play in the ongoing care of mental health patients, a responsibility they cannot overlook. This duty is accentuated by the mental health care policy in Thailand, which prioritizes efficient community-based care to minimize hospitalization durations and facilitate the patients’ reintegration into their families. ^{2 , 6} Consequently, psychiatric patients are frequently reintegrated into the community, prompting CNs to undertake expanded responsibilities in addressing mental health concerns within their localities. ^{2 , 10}

The study underscores the overarching theme of “Confronting role expansion in long-term psychiatric care responsibilities,” emphasizing the crucial role of CNs in ensuring the continuity and quality of mental health care services. It highlights the necessity of expanding CNs’ roles to encompass the holistic management of psychiatric patients within the community, including direct patient care, case management, and coordination with other healthcare providers. ^{2 , 8} CNs are essential in identifying and managing psychotic symptoms such as hallucinations and delusions, which often result from inconsistent medication adherence and substance use and are stimulated by high stress. Providing continuous long-term care is vital to ensure that the patients adhere to their medication regimens and effectively manage their symptoms. By offering clinical support, emotional assistance, and psychoeducation, CNs significantly reduce hospital readmissions and enhance the safety and well-being of patients, families, and the broader community. ^{6 , 7}

Despite the dedicated efforts of CNs, it has become apparent that their well-meaning endeavors may not always suffice to achieve profound healing for patients, particularly those grappling with severe mental health conditions, as elucidated in the theme of ‘Insecurity in ambiguity role’. CNs’ responsibilities encompass a range of tasks, including home visits, medication adherence oversight, stress reduction recommendations, and coordination of welfare support to reduce recurrence and readmission rates. ² However, these measures may not fully alleviate the inner suffering experienced by patients, especially in severe and emergency cases. ¹⁹ Acknowledging the limitations of their expertise and patients’ complex psychological needs has left CNs feeling insecure in their roles as caregivers. The realization that patients often require specialized psychotherapeutic interventions beyond the scope of their usual care has generated feelings of distress and uncertainty. ²⁰ This resonates with findings from systematic reviews, which suggest that insufficient knowledge and skills among healthcare providers can lead to inefficiencies, frustration, and psychological challenges. ^{6 , 21} Addressing these challenges necessitates a multifaceted approach. Primarily, there is a pressing need to enhance CNs’ competencies in psychiatric care through targeted training and education. Such initiatives would bolster their capacity to deliver effective psychotherapy and other specialized interventions. Additionally, fostering closer collaboration between CNs and psychiatric specialists is crucial for meeting the diverse needs of patients. ⁶ Effective communication between CNs and specialists is paramount in facilitating a seamless continuum of care. ⁶ Home visits must be optimized and tailored to patients’ and families’ unique problems, contexts, and conditions. ¹⁹ Adopting online home visit models may prove beneficial in this regard. Simultaneously, efforts to reduce the stigma surrounding mental illness must be intensified, involving both CNs and the broader community. ²² This approach not only bridges the gap in continuing care but also alleviates the suffering experienced by patients, families, and CNs. In essence, addressing CNs’ feelings of insecurity and role ambiguity requires concerted efforts to enhance their skills, foster collaboration, optimize care delivery methods, and combat stigma. These initiatives can significantly improve the quality of mental health care CNs provide, leading to better outcomes for patients and caregivers.

This study underscores the profound awareness among CNs regarding the necessity of psychiatric care and their unwavering dedication to helping patients reclaim their dignity and value as human beings within the community. This commitment is epitomized by the theme of ‘Duty of supportive caring for marginalized people’. CNs recognize the intricate nature of chronic psychological conditions and emphasize the importance of comprehensive support. Their goodwill and compassion are pivotal in fostering trust, safety, and confidence in healing. Indeed, this therapeutic relationship emerges as a potent curative factor in psychiatric therapy. ²³ The qualities of empathy, compassion, and understanding exhibited by CNs in building therapeutic relationships with patients serve as strengthening factors in the therapeutic process for psychiatric patients, contributing significantly to the humanitarian aspect of nursing. The positive experiential changes resulting from this humanitarian work are as powerful as the clinical healing process. ^{20 , 21}

Stakeholders, particularly policymakers, wield significant influence in bridging the gap through the professional development of CNs. This entails focusing on specialized skills that foster trust, adopting a positive approach to screening and assessment, providing brief psychotherapy, and facilitating referrals to experts. CNs must have access to comprehensive continuing education rather than short training sessions. Implementing standard protocols and guidelines can further augment the quality of care provided. Concurrently, efforts to reduce stigmatization surrounding mental health must be prioritized. ⁷ Effective communication and collaboration between CNs and specialists are paramount for addressing the complex needs of patients. ⁶ To enhance the efficiency of home visits, authorities should make concerted efforts to adopt patient-centric approaches and explore the potential integration of online models. Simultaneously, community awareness campaigns should be conducted to combat mental health stigmatization. ²⁰ This collective endeavor holds promise in enhancing continuing care and alleviating the suffering experienced by patients, families, and CNs alike. ²⁴

This study findings offer significant implications for advancing and refining psychiatric care within the primary care system. With the insights derived from this research, there is a critical suggestion for enhancing the nation’s mental health policies to develop community-based mental health care for facilitating the patients’ return to their families by providing CNs training, workshops, seminars, and online courses with a focus on crisis intervention, de-escalation techniques, collaborative care approaches, and through humanizing psychiatric care to empower psychiatric patients and families to reclaim their dignity and well-being. Establishing mentorship can build confidence and competence in managing mental health crises. We need to foster collaboration between CNs and mental health specialists to ensure comprehensive patient care, which involves regular case discussions, joint home visits, and shared care plans to address the holistic needs of individuals with mental health issues. These strategies enable them to realize their full potential in advancing psychiatric care. To gain a better understanding, future studies should incorporate diverse perspectives regarding the patients’ and their families’ opinions, thereby contributing to comprehending psychiatric care within the community.

One limitation of this study is its exclusive focus on the southern region of Thailand, which limits the findings to CNs in other areas or diverse settings. However, the study provides valuable insights with significant implications for improving psychiatric care within the primary care system. The findings highlight the need to enhance the nation’s mental health policies by developing community-based mental health care and providing targeted training for CNs, ultimately facilitating the patients’ reintegration into their families.

CONCLUSION

Thai CNs face significant stress when providing care for psychiatric patients, grappling with their acknowledged lack of specialization and essential expertise in the field. Alongside the issue, they knew that supportive caring for marginalized people is their duty to humanity. These findings illuminate crucial dimensions for enhancing patient care and professional practices in psychiatric nursing. They underscore the indispensable role of CNs within the mental health landscape while also delineating areas ripe for potential improvement and support to augment the quality of psychiatric care. It is imperative to prioritize the development of CNs’ skills through the implementation of continuing education modules and the establishment of comprehensive nursing practice guidelines. Such education should encompass a spectrum of competencies, emphasizing fostering positive connections with patients and families, actively alleviating their suffering, and delivering care tailored to their unique needs. Furthermore, policymakers within the healthcare system must thoroughly comprehend the challenges faced by CNs and acknowledge their pressing needs. Providing unwavering support is paramount in this regard. This support should encompass a range of educational initiatives, allocation of resources, and implementation of strategies aiming at assisting CNs in navigating the complexities of mental health stigmatization. Efforts to promote awareness and understanding are essential, empowering individuals to overcome stigmatization barriers, embark on a trajectory toward recovery, and ultimately enhance the overall quality of care delivered within community psychiatric nursing practice. Future studies should incorporate diverse perspectives, including those of patients and their families, to gain a comprehensive understanding of psychiatric care within the community. This approach will contribute valuable insights for formulating strategies to improve CNs’ contributions in caring for psychiatric patients and their families within the primary care system.

ACKNOWLEDGEMENT

We sincerely thank all participants and the Thailand Nursing and Midwifery Council for the supporting scholarship.

Conflict of Interest:

None declared.

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