Mental health nurses and disaster response in Sierra Leone
Authors: Dawn Harris, Alie Wurie, Florence Baingana, Stephen Sevalie, Fenella Beynon
Journal: The Lancet Global Health (2018)

On Aug 14, 2017, Sierra Leone was hit by a deadly mudslide and catastrophic flooding. Over 500 people were confirmed dead, with hundreds more reported missing. An estimated 5951 people have been affected,1UN Disaster Assessment and Coordination Sierra Leone landslide and floods update, no. 8. Aug 31, 2017https://reliefweb.int/sites/reliefweb.int/files/resources/Sierra%20Leone%20Sit%20Update%20no%208.pdfGoogle Scholar many of whom have been displaced and have restricted access to food, water, shelter, or safety. The disaster led to widespread disruption of families and the loss of entire communities. Multiple actors engaged in response efforts coordinated by the Office of National Security. We would like to highlight the unique and important role of mental health nurses in Sierra Leone. Mental health sequelae are well recognised after a disaster. Some groups of people have an increased risk of developing adverse psychosocial consequences; these groups include poor people, pregnant women, unaccompanied children, those with pre-existing mental health disorders, and those exposed to extreme stress such as loss of a loved one.2Inter-Agency Standing Committee IASC guidelines on mental health and psychosocial support in emergency settings. Inter-Agency Standing Committee, Geneva2007Google Scholar Flooding can lead to both transient and sustained psychosocial consequences, and it can be difficult to distinguish distress from common mental disorders. Efforts to reduce primary and secondary stressors should be incorporated into the response to promote long-term recovery.3Stanke C Murray V Amlôt R The effects of flooding on mental health: outcomes and recommendations from a review of the literature.PLoS Curr. 2012; 4 (e4f9f1fa9c3cae)PubMed Google Scholar Psychological first aid (PFA) is endorsed by many international agencies and is widely used in disaster response efforts. It can be delivered by any PFA-trained individual and aims to provide immediate support to affected individuals and help mitigate risk factors for mental illness. Scientific evidence for the effectiveness of PFA is scarce, but it is supported by a consensus of expert opinion.4Dieltjens T Moonens I Van Praet K De Buck E A systematic literature search on psychological first aid: lack of evidence to develop guidelines.PLoS One. 2014; 9: e114714Crossref PubMed Scopus (82) Google Scholar Sierra Leone has 20 mental health nurses, reflective of a general low health worker to population ratio. The mental health nurses are well versed in PFA and many are experienced PFA trainers. Their experience allowed them to deploy immediately to deliver PFA to affected individuals, whereas other responders first required refresher training. Within 1 week after the mudslide, the nurses delivered over 1000 interventions to affected individuals. They also led in-depth PFA sessions with mortuary staff, ambulance workers, and burial teams because these workers were deemed potentially susceptible to development of psychological sequelae. All 20 mental health nurses are also trained general nurses with a minimum of 3 years' clinical experience. This broad base in experience and expertise allowed them to do multiple roles to help meet the needs of the affected population. Their general nursing background assisted with the recognition and referral of medically unwell individuals for treatment and delivery of nutritional or infection control advice. In disaster situations, human resources might be limited so versatility is advantageous. Mental health nurses were also stationed at two government hospitals where most of the injured people were taken. The nurses have experience in providing psychiatric liaison services. They built on their mental health expertise to provide in-depth support to affected individuals and their families. Using a holistic approach to patient care, they provided a crucial role for individuals with complex medical and psychological needs, particularly advocating for those who did not have family members to help. As the response progressed and patients with more difficult situations began to emerge, the mental health nurses acted as the specialist referral point on the ground for multiple organisations delivering PFA. This referral system enabled immediate follow-up of more complex patients who might have struggled to reach formal mental health units. Certain individuals received daily follow-up and small numbers were treated with psychotropic medications. Individuals with pre-existing mental health disorders who had not previously presented to services also benefited. The mental health nurses engaged with the media to highlight psychological support needs and services; they also used this opportunity to raise awareness of mental health at a national level. Estimates have placed the mental health treatment gap in Sierra Leone at 99·5%.5Alemu W Funk M Gakurah T et al.WHO Profile on mental health in development (WHO proMIND): Sierra Leone. World Health Organization, Geneva2012Google Scholar The multisectoral and media engagement with psychological needs will hopefully contribute to normalising the concept of mental health in Sierra Leone, where stigma remains a key barrier to accessing services. The rapid mobilisation of mental health nurses in the aftermath of the mudslide and floods in Sierra Leone proved a crucial part of the psychological support response. The nurses provided a high quality of care in difficult circumstances, building on their previous expertise and showing adaptability to multiple working environments. Their input should be incorporated into future disaster response plans, but with consideration given to the effect of their involvement on routine mental health service delivery. This experience highlights the value of mental health nurses in Sierra Leone, the need for recognition of mental health as a nursing specialty, and the further training of specialist mental health staff. We declare no competing interests. We acknowledge the mental health nurses of Sierra Leone, including child and adolescent mental health nurses, for their dedication and invaluable work; the Ministry of Health and Sanitation Sierra Leone for their coordination and leadership; World Health Organization and US Agency for International Development (USAID) for providing the necessary funding; and Building Back Better and Kings Sierra Leone Partnership for their participation in the coordination. The research was supported by USAID through the Advancing Partners and Communities project, implemented by John Snow Incorporated Research and Training Institute, in collaboration with FHI 360 under Cooperative Agreement No. AID-OAA-A-12-00047. The opinions are those of the authors and do not necessarily reflect the views of USAID.