Respect for service users’ human rights,job satisfaction,and wellbeing are higher in mental health workers than in other health workers: A study in Italy at time of the Covid pandemic

Abstract

Background:

This study aimed to evaluate the respect for users’ rights, job satisfaction, and well-being between mental health workers (MHWs) compared to non-mental health care workers (nMHWs) from the same Italian region.

Methods:

The sample was recruited from community mental health and non-mental health outpatient centers in Sardinia. Participants fulfilled the WellBeing at work and respect for human-rights questionnaire (WWRR). The sample included 240 MHWs and 154 nMHWs.

Results:

MHWs were more satisfied with their work and workplace compared to nMHWs. MHWs had stronger beliefs that users were satisfied with the care received, and both workers and users’ human rights were respected in their workplace. MHWs reported to need more rehabilitation therapists and psychologists in their services, while nMHWs needed more nurses and professionals for users’ personal care.

Italian MHWs are more satisfied with their work and workplace, and more convinced that users are satisfied with the care received and that users’ and staff human rights are respected in their workplaces, compared to nMHWs.

Conclusions:

Keywords

Users health workers human rights job satisfaction organization wellbeing mental health

Introduction

In mental health care services, the rights of users are not always respected, as denounced by several reports from international organizations working on human rights, first and foremost the United Nations High Commissioner for Human Rights.¹

A climate of disrespect for the human rights of users may affect the well-being of health workers; in fact, the perception of the respect of users’ rights by health professionals of mental health facilities is believed to be a fundamental component of organizational well-being in mental health services.^2–4 It was confirmed by a recent study that the principal component analysis of the questionnaire “Well-Being at Work and Respect for Human Rights Questionnaire “(WWRR) found that the six main items of the questionnaire (which investigate the perception of respect of users’ rights, job satisfaction and the perception of well-being at work) are solved by a single component, thus confirming the assumption that there is a relationship between the perception of respect for users’ rights and the well-being of professionals.⁵

A similar study that adopted the same tool and conducted a comparison between health workers of mental health facilities in Italy, North Macedonia, Gaza, and Tunisia found that Italian staff had given the highest scores on the item about believing that users’ rights were most respected in their care services. Furthermore, Italian staff was the most satisfied with their workplace.⁶ This could be the result of the fact that in Italy (a unique case in the world) psychiatric treatments all take place in the community and not in psychiatric hospitals. Therefore, the proximity to the places of life and the social community of the user make it easier to respect their rights. However, it should be emphasized that Italy is a richer country compared to others, and although in a moment of crisis of health and mental health services and given the different resources available in the treatment centers, a direct comparison can therefore be distorted by this factor.^7–9

For this reason, it would be more interesting to conduct transnational comparisons not on the scores achieved in completing the questionnaire in the mental health centers of the different countries, but instead, on the possible differences between scores in mental health services and in other care services in each country. As it is assumed that mental health care services do not offer the same respect for citizens’ rights as other care services, the comparison between the two conditions in the same country could be an indicative factor (provided that they have not violated the users’ rights also in all health care agencies). Moreover, specifically in Italy, given that this country has shown a good level of satisfaction of mental health workers compared to other countries, the comparison of mental health workers toward others health workers can be a pivot for other transnational comparisons.

The purpose of this study is to measure the perception of respect for users’ rights, job satisfaction, and organizational well-being in mental health workers from an Italian region against a comparable sample of non-mental health care workers in the same area.

Methods

Design: Cross Sectional Study.

Sample

A volunteer sample of health workers was recruited from three non-mental health outpatient centers working in southern Sardinia (pain therapy, dermatology, ophthalmology of the “San Giovanni di Dio” Center in Cagliari) and in three community mental health centers in in the same geographical area. The study was conducted at participants’ workplace.

Study tools

Each participant filled the following tools:

A sociodemographic questionnaire asking about: Age, Gender, Occupational Role, Place of employment.

Well-Being at work and respect for human rights questionnaire (WWRR). The tool was inspired to the World Health Organization initiative Quality Rights on the implementation of the Convention on the Rights of Persons with Disabilities in the filed od psychosocial disability.^10–14 The aim of the tool is to measure how users and health workers perceive the respect for the human rights of both users and staff in the workplace and if this perception is associated to the organizational well-being within the service (for health workers) or the personal well-being (for service users).

The questionnaire was developed with inputs by mental health service users and health professionals including psychiatrists, medical doctors, rehabilitation professionals, and psychometrists. The original version has been developed in Italian and English and translated in several languages. The first five core items are collected in a Likert scale from 1 to 6, with 1 “Not satisfied at all” to 6 “Completely satisfied” from item 1 to 5. The coding is inverse in item 6 which measures the adequacy of resources in the workplace in a Likert scale from 1 to 5. Another item explores the perception of the need for human resources (what kind of professionals) in the place of work. The tool was described in detail in the paper about validation.⁵

Statistical analysis

Statistical analysis was conducted by comparing the responses to the items in the two groups, obtained after standardization for age (≥39 vs ≤40) and sex (male vs female). The standardization was carried out keeping as a basis the percentage breakdown of mental health workers. The analysis was carried out by ANOVA 1 way test.

Ethics

The Independent Ethical Committee of the University Hospital of Cagliari, Italy approved the protocol of the survey. The study has been carried out in agreement with the guidelines of the 1995 Declaration of Helsinki and its revisions.¹⁵

Results

The final sample included 374 health workers (240 in mental health facilities, 154 in non-mental health facilities). The sample characteristics are presented in Table 1: A slight age imbalance emerges in the two samples, with a higher representation of older workers aged 50 or over in the sample of mental health workers (53.3% vs 42.2% OR 1.50 (CI 95% 1.0–2.3).

Table 1.

Socio-demographic characteristics of the study sample.

		Mental health facilities, N (%)	Other facilities, N (%)
Gender	Men	68 (28.3)	61 (39.6)	OR 0.51 (CI 95% 0.3–0.8)
Age	>49	128 (53.3)	65 (42.2)	OR 1.50 (CI 95% 1.0–2.3
Occupation	Medical Doctor	37 (15.4)	52 (33.3)	0.36 (0.2–0.6)
	Nurse	105 (43.75)	73 (46.8)	0.88 (0.6–1.3)
	Other	108 (45.0)	29 (18.6)	3.58 (2.2–5.8)

In the responses to the WWRR questionnaire, health workers in mental health care, compared with health workers from other health care facilities, report higher work satisfaction (Item 1, score 4.43 ± 0.98 against 4.09 ± 1.37, F = 6.912, p = 0.009), higher perception that the users of their service are satisfied (Item 2; 4.43 ± 1.20 against 4.09 ± 1.37, F = 6.465, p = 0.011); a higher satisfaction with the organizational aspects of their work (Item 3; 3.91 ± 1.32 against 3.24 ± 1.33, F = 23.193, p < 0.0001). Furthermore, they show higher scores at the item regarding the respect for service users’ human rights in their workplace (Item 4, score 5.09 ± 1.13 against 4.53 ± 1.30, F = 19.635, p < 0.0001); and higher scores at the item regarding the respect for health workers’ human rights in their workplace (Item 5, score 4.51 ± 1.29 against 3.88 ± 1.48, F = 19.430, p < 0.0001) (see Table 2).

Table 2.

Answers at items 1–6 of WWRR: Comparison between mental health workers and other health care workers.

	(1) How satisfied are you with your work?	(2) How much you believe that the users of the service in which you work are satisfied?	(3) How satisfied are you with the organizational aspects of your work /how your work is organized?	(4) To what extent do you believe that the human rights of the people who are cared for in your service are respected?	(5) To what extent do you believe that the human rights of the staff working in your service are respected?	(6) How do you evaluate the current state of care in your service/ward, with reference to resources?
Mental health services workers, (N = 240)	4.43 ± 0.98	4.43 ± 1.20	3.91 ± 1.32	5.09 ± 1.13	4.51 ± 1.29	3.29 ± 0.85
Workers in other health facilities, (N = 154)	4.15 ± 1.06	4.09 ± 1.37	3.24 ± 1.33	4.53 ± 1.30	3.88 ± 1.48	3.10 ± 0.94
F (df 1392)	6.912	6.465	23.193	19.635	19.430	4.146
p	0.009	0.011	<0.0001	<0.0001	<0.0001	0.042

In the item evaluating the perception of the quality of care in relation to resources (Table 2), staff working in mental health centers are more dissatisfied than those in non-mental health care centers (Item 6, score 3.29 ± 0.85 against 33.10 ± 0.94, F = 4.146, p = 0.042). We found also strong differences in the perception of the need for professional figures (Table 3). Staff working in mental health centers declared greater need of occupational therapists/educators/technicians of rehabilitation (30% vs 9.7%, OR 0.80, CI 95% 0.21–3.02); psychologists (26.4% vs 13.6%, OR = 2.06, 95% CI 1.19–3.56); and medical doctors (27.1% vs 15.6%, OR = 2.01, 95% CI 1.19–3.38). On the contrary, staff working in health centers other than mental health declared greater need of nurses (28%, and .6% vs 8.8%, OR = 0.24, CI 95% 0.13–0.92) and professionals providing personal care to service users (23.3% vs 5%, OR = 0.17, CI 95% 0.11–0.41). Furthermore, nMHWs also declared more frequently that there is no need of more professionals in their workplaces (5.8% vs 0%; OR = 0, CI 95% not calculable). There was no difference in the perception of the need for more social workers and staff employed in security services.

Table 3.

Needs for type of health workers in the service in which I work (Item 7 WWRR).

	Mental health facilities, N (%)	Other facilities, N (%)	Chi square (with Yates correction if needed)—p	OR (CI 95%)
Nurses	21 (8.8)	44 (28.6)	26.75—p < 0.0001	0.24 (0.13–0.92)
OSS—Professional for personal care	12 (5)	36 (23.3)	29.61—p < 0.0001	0.17 (0.11–0.41)
Medical doctors	65 (27.1)	24 (15.6)	7.09—p = 0.008	2.01 (1.19–3.38)
Psychologists	59 (26.4)	21 (13.6)	6.95—p = 0.008	2.06 (1.19–3.56)
Occupational therapists/educators/technicians of rehabilitation	72 (30)	15 (9.7)	6.94—p = 0.008	3.97 (2.18–7.23)
Social workers	5 (2.5)	4 (2.6)	0.001*—p = 0.999	0.80 (0.21–3.02)
Staff security	7 (2.9)	1 (0.6)	0.141*—p = 1.418	0.59 (0.56–37.7)
None needs to be incremented	0	9 (5.8)	11.85—p < 0.0001	0 (NC)

Yates correction.

Discussion

The study shows that the Italian health workers of mental health services were more satisfied with their work and the organization at their workplace. They were also more convinced that users are satisfied with the care received and that the human rights of both users and health workers are respected in their workplaces, compared with health professionals who work in providing non mental health care for outpatients in the same geographical area. However, the mental health services staff are less satisfied with the level of the quality of care offered in relation to the resources available, and these workers’ perception of fewer resources is also consistent with the answer to the item on the type of staff needed, where none of the workers in mental health services declared that there is no need for personnel against a not negligible percentage of the control sample. In the mental health services the number of rehabilitation figures, psychologists and doctors is considered insufficient, in the other services it is considered insufficient the personnel assigned to support people in their personal care and nurses. There were no differences in the perception of shortcomings in relation to social workers and, importantly, to security staff.

Two aspects characterize mental health care in Italy. The first is that in this country there are no longer psychiatric hospitals, and all the treatments are provided widely in the area near the places of residence of the users, who are also supported for their social inclusion and work^16,17 in a strict link with the other support networks. The second is that, in recent years, there has been an alarming decrease of available resources for mental health (Ministero della Sanità 2016).^18,19 The fewer health resources are a consequence of the economic crisis which has progressively worsened in the last 15 years in Italy and has had a greater impact on the mental healthcare network than in other sectors. Furthermore, the expenditure on mental health in Italy has progressively decreased to an average 3% of the total health expenditure while in other European countries, with an income similar to Italy, it is around 8–10% of total health expenditure.⁷

Up to now, in Italy, most of the specialized medical treatments not for mental health, in contrast with mental health facilities, have been provided by centers located in a hospital structure, and sometimes distant from other social support network. These distances from social communities has been amplified by the Covid pandemic because in great and complex health structures, such as hospitals, the problem of distancing has increased waiting times and lengthened the queues. Moreover, general healthcare professionals were under pressure while in mental health community facilities, where small well-knit teams worked, these contingencies were faced more easily. Furthermore, many community mental health care services in Italy organized themselves in an extremely practical way, adopting telemedicine as much as possible, reserving visits in presence for emergencies,^8,20,21 and organizing support and educational interventions for families of users under stress due to Covid pandemic.^22,23 The social networking deriving from a knowledge and rooting of the teams in the community (with the help of the social services of the municipalities and voluntary networks where present) allowed a better monitoring of critical situations. These responsiveness and resilience meant that recent research on the well-being of mental health personnel in Italy during Covid did not find the situation worsened²⁰ unlike research on other health professionals that found higher level of anxiety and depression.^24,25

It can be hypothesized that the community organization of mental health care is at the basis of a better perception of subjective well-being, organizational well-being, users’ satisfaction and respect for human rights by the staff of mental health services in Italy compared to the other specialized care agencies that are still geographically and structurally linked to a hospital-centered model. Moreover, the previous international comparative research found mental health Italian professionals as those with the best scores at WWRR compared to mental health workers in other countries, who, unlike Italy, mainly work in hospital centered mental health facilities.⁶ However, in this case future studies should verify the results in countries socio-economically more similar to Italy.

It should be noted that these encouraging results occur even though mental health professionals are aware of and complain of lower quality of care in relation to the scarcity of resources. Basically, although they are still working with satisfaction and motivation, mental health workers realize that the amount of resources appears to influence the quality of care and this is in line with several surveys in Italy.^26,27 It should be underlined that in item 7 of WWRR Questionnaire, which investigates this aspetc, the scores in Italy were not higher than those of other countries.⁶

While non-Italian reports have sometimes denounced the exposure to violence of MHWs,²⁸ in our sample there are no statistically significant differences in the need for staff security between the two samples compared. This perception of safety, or at least this not highlighted alarm for insecurity of MHWs in community care in Italy, might be a determining factor for these results.²⁹

The choice of professional figures that the assistance network needs is a confirmation of the staff’s motivation for the community culture of care (in fact, they declared that they need rehabilitation technicians and psychologists in the first place) but, at the same time, is an alarming sign: It denounces that the key figures of community assistance and social inclusion are lacking, primarily rehabilitation technicians and psychologists as well as doctors.

Limits

The study has clear limitations consisting of the voluntary nature of the sample, the geographical non-representativeness extended to the whole national territory and the lack of comparisons in the literature with countries of income and health system comparable to Italy (except for the health care system community centered which is the peculiar characteristic of Italy and which the study hypothesizes to be the basis of the good level of satisfaction of mental health workers). Another limitation is that the users’ point of view has not been taken into consideration in the present study (collection of data on this aspect is ongoing). Yet the findings are so relevant that the work suggests conducting future studies.

Conclusions

Italian mental health workers are more satisfied with their work, more satisfied with the organization at their workplace, more convinced that users are satisfied with the care received and that the human rights of users and health workers are respected in their workplaces, compared with health personnel working in tertiary outpatient care facilities not for mental health in the same geographical area.

The historic link between the community mental health network and other support networks in Italy and the consequent perception of proximity to the citizens of the care network may be the reason for this optimal situation of mental health staff. However, mental health workers complain of a reduced quality of care in relation to the scarcity of resources which reflects the trend on public spending on mental health in recent years in Italy.

Future studies will have to verify these data with larger samples, international comparisons and with the users’ point of view.

Another important point is that the study did not find higher needs for security staff in mental health services, this perception of safety favors a climate that may limits coercive interventions.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The present study is supported by Legge 7, Regione Sardegna, 2017, Italy

Ethical approval

Significance for public health

The data demonstrate the historic link between the community mental health network and other support networks in Italy and underline the consequent perception of proximity to the citizens of the care network as reason for this optimal situation of Italian mental health workers. Another important point is that the study did not find higher needs for security staff in mental health services, this perception of safety favors a climate that may limits coercive interventions and improve quality of care.

Data and material availability

The research data related to the study would be made available by the corresponding author on reasonable request

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