Exploring the Experiences of Non-Psychiatric Professional Nurses Regarding Care of MHCU’S with Medical Conditions in General Wards of Limpopo Province, South Africa

1. Introduction

Non-psychiatric nurses are professional nurses who has met the prescribed educational requirements for registration as a professional nurse according to SANC regulations. They are not allowed to care for Mental Health care users (MHCUs) according to Mental Health Care Act [1].

Non-psychiatric nurses are required to have the necessary knowledge and skills to manage MHCUs with medical conditions without being hurt in the process. To do this professional nurse, need to be educated and trained in understanding mental illness and how it has impact on a patient’s behavior [2] (DOH, 2008).

Fear may be one of the challenges faced by non-psychiatric nurses which may prevent them from effectively caring for MHCUs admitted for physical conditions in general hospitals. Their fear might be the perception of unpredictability and dangerous behaviour posed by MHCUs; therefore, causing professional nurses to be hyper vigilant and concerned for their own safety and that of other patients {3} (Bjorkman, Andersson, Bergström & Erikson, 2018).

According to Mental Health Care Act [1], psychiatric nurses must render services to MHCUs, and alludes that MHCUs should be treated with dignity and their privacy always respected. Their treatment should be appropriate to their mental health status and should intrude as little as possible to provide the effect of appropriate care, treatment, and rehabilitation.

However, MHCUs are admitted in general and surgical wards with medical and surgical conditions, where non-psychiatric professional nurses render services for medical and surgical conditions. Mental health condition of the MHCUs is mostly neglected as the focus is on the medical and surgical condition which may lead to relapse.

Relapsed MHCUs may be unpredictable and difficult to manage due to unacceptable behaviour which they display, they may disrupt the normal ward routine and be a challenge to non-psychiatric professional nurses who does not know what to do to manage the behaviour. Due to lack of knowledge and skills for non-psychiatric professional nurses, MHCUs may be dangerous to fellow patients and staff.

Non-psychiatric professional nurses who do not know what to do to manage the behaviour of relapsed MHCUs due to lack of knowledge and skills, ask for assistance from psychiatric wards which is difficult due to shortage of psychiatric nurses and causes delay when psychiatric nurses in psychiatric wards are busy with their routine.

Mental health care users who relapse being admitted in general wards, managed by non-psychiatric professional nurses may consequently cause multiple incidences such as assaults, injuries, and damage to property, that can later turn into litigations against the department of health [4].

Rutherford [5], also report that non-psychiatric professional nurses in general wards often lack knowledge and skills in the management of mental health needs of MHCUs, which may lead to suboptimal care and discrimination of MHCUs.

This is supported by Campbell, Duncan & Bawden [6], reported that the non-psychiatric professional nurses are likely to compromise on quality of care for the patients partly due to lack of knowledge and skills in the management of mental health care users.

Furthermore, Niu, Kuo, Tsai, Kao, Traynor and Chou [7], reported that experiencing unpredictable behaviour displayed by relapsed MHCUs in general wards may have negative consequences which include psychological harm, physical injuries or even death to staff members and other patients admitted for medical and surgical conditions.

Alexander, Ellis, and Barrett [8], reported that fear may be one of the challenges faced by non-psychiatric professional nurses which may prevent them from effectively caring for MHCUs admitted with medical and surgical conditions in general wards due to the perception of unpredictable behaviour by relapsed MHCUs.

Madlala, Miya and Zuma [9], indicated that fear may be one of the challenges faced by non-psychiatric professional nurses which may prevent them from effectively caring for MHCUs admitted for physical conditions in general wards.

Therefore, this study explored the experiences of non-psychiatric professional nurses regarding care of MHCUs in general wards, specific information that non-psychiatric professional nurses need in caring for MHCUs admitted in general wards.

• Definition of concepts

General hospital is a hospital that is equipped to care for medical, surgical, maternity and psychiatry and does not specialize in the treatment of illnesses or patients; different types of ailments are treated, the role of the general hospital is to allow patients with different illnesses to be treated as outpatients or inpatients [10] (Huggins, 2016). The general hospital which was used in the study is the one with a psychiatric ward and the general ward where MHCUs are taken care of by professional nurses without training in psychiatry.

General ward is found inside the general hospital and has allocated number of beds for admission of patients in need of care for medical and surgical conditions. The role of a general ward is to allow patients with different illnesses to be admitted and treated in totality as narrated by participants of this study during interviews [11] (Lyketsos, Sheppard & Rabins, 2014). The study used general wards which manage general conditions.

Mental health care user is a person receiving care, treatment and rehabilitation services or using a health service at a health establishment aimed at enhancing the mental health status of a user [12] (Uys & Middleton, 2014). The study referred mental health care user to MHCUs admitted in general ward.

Non psychiatric nurse is an individual who according to the Nursing Act [13] no. 33 of 2005, is qualified and competent to independently practice comprehensive nursing in a prescribed manner; one who can assume responsibility and accountability for his or her actions. In the study a nurse means a professional nurse without psychiatry rendering services to MHCUs admitted in general wards.

2. Materials and Methods

2.1. Study Design/Setting

Since the purpose of the study was to explore the experiences of non-psychiatric nurses in caring for MHCUs admitted in general wards, qualitative approach using explorative, descriptive, and contextual design using individual interviews was used to allow professional nurses without psychiatry to narrate their experiences and the kind of information that they need in caring for MHCUs admitted in general wards without any limitation, which could not be achieved by quantitative approach.

The study was conducted in the Limpopo Province, South Africa, which consists of five districts. Two districts out of five districts in Limpopo Province were selected using simple random sampling. Two regional hospitals were selected using purposive sampling; therefore, the study was conducted in four general hospitals of Limpopo Province, South Africa which is two districts’ hospitals and two regional hospitals.

The study explored the experiences and the kind of information that the professional nurses without psychiatry need in caring for MHCUs admitted in general wards. The explored data supported by literature control.

2.2. Study Population

The study involved twenty professional nurses without psychiatry, who are directly responsible for caring for MHCUs admitted with medical conditions in general wards, Limpopo Province and meet the criteria of inclusion in the study.

2.3. Sampling Method

• Sampling of the districts and regional hospitals

Simple random sampling was used to select two out of five districts and two district hospitals from the sampled districts in Limpopo Province. Purposive sampling was used to select two regional hospitals from two sampled districts.

• Sampling of the participants

The study used convenience sampling to select conveniently available non- psychiatric professional nurses who met the criteria of inclusion in the study. Non- psychiatric professional nurses were approached and informed about the study. Those who agreed to form part of the study were included to participate in the study. The actual number of participants depended on data saturation; however, the anticipated number of participants was twenty.

This is indicated in Table 1 below:

2.4. Data collection

All participants were listed and contacted telephonically, rapport was created, and they were recruited to participate in the study. The study was explained briefly, their consent was requested, and an appointment was made in a place where they would feel comfortable, at a time convenient to them. The date, time and venue were agreed upon with the participants. The participants were informed that they are under no obligation to participate in the study, and that if they do participate, they do have the right to withdraw at any stage of the interview with no penalty. The use of an audio recorder was explained that it would be used to record the interview, and the recording may be stopped at any time if the participant wanted it stopped. Data was collected through individual interviews with participants. The interviews were conducted in English as agreed with the participants and lasted for 30 to 45 minutes.

The interview was directed by the following central question which was followed by probing questions:

Kindly share with me about what you experience every day as you are providing care to MHCUs admitted with a medical condition in general wards.

Pre-testing was done to test if the research question is clear and easy to understand by the participants and to test the voice recorder to be used during individual interviews. Two non-psychiatric professional nurses who met the criteria of inclusion for the study were selected from other hospitals which did not form part of the study. They were interviewed as a way of testing if the research question is clear to the participants of this study and to check if the voice recorder was functioning well.

• The role of the researcher

Effective communication skills were used to facilitate the semi- structured individual interviews. Rapport was established and displayed an attitude of unconditional acceptance, respect, empathy, honesty, and openness was displayed throughout the interview.

Participants were encouraged to feel free to explain their experiences and that no name will be mentioned during the interview, and there is no right or wrong answer, just a differing in the points of view. Participants were thanked for their participation at the end of the interview. Data was collected until saturation.

2.5. Ethical Consideration

Ethical approval for this research was obtained from the Institutional Research Ethics Committees Project number: SHS/19/PDC/10/1005, HOD of Limpopo Province in South Africa, Districts, and sampled hospitals. The aim of the study, duration and its significance were clearly explained to the participants before they could consent to participate in the study. The non-psychiatric professional nurses were informed that they may withdraw from the study at any time, and they won’t be questioned of their actions. They were requested to sign the consent form which they did freely.

2.6. Data Analysis

Data analysis was guided by Tesch, cited in Creswell [14]. Transcribed data were read for several times to gain overall meaning of the responses given by participants. The data were then arranged into themes and sub themes and labelled using the actual words and language of participants. Two themes emerged after data were arranged, which were the major findings of the study. Furthermore, identified themes was cross-checked and interpreted, wherein they revealed what was learnt about experiences of professional nurses without psychiatry in caring for MHCUs in general wards.

3. Results

3.1. Presentation of results

• Descriptionof sample

The study population was twenty professional nurses without psychiatry, directly responsible for caring for MHCUs admitted with medical conditions in general wards, Limpopo Province, South Africa, of whom eighteen were females and two were males as classified according to gender. Sample involved participants from medical wards nine and surgical wards one as classified according to conditions. Participants from male general wards were nine and one from female general wards as classified according to gender of the ward. The sample size depended on the saturation of data.

Data was analysed using Tesch’s eight steps of data analysis. Data analysis revealed two themes and sub-themes. Themes that emerged were: Managing psychiatric patient, Types of patient’s behaviour. These themes as well as sub-themes are discussed in detail with direct relevant quotations from the transcripts to enrich the data. The discussion of the literature follows this directly and serves to confirm the findings.

Themes and their sub-themes emerged during data analysis and are discussed below.

Theme 1. Managing Mental health care users.

Table 2. Theme 1 and sub-themes.

THEME	SUB-THEMES
Managing Mental health care users	Request assistance and advice from mental health care ward

Table 2. Theme 1 and sub-themes.

THEME	SUB-THEMES
Managing Mental health care users	Request assistance and advice from mental health care ward

Theme 1 emerged during analysis of data when participants indicated their experiences regarding care for MHCUs admitted in general hospitals. One Sub theme out of this theme was identified namely, Request assistance from mental health care ward as described below.

• Request assistanceand advice from mental health care ward

Data revealed that non-psychiatric professional nurses are unable to manage mental health care users independently without seeking assistance from the mental health care ward. Furthermore, they also indicated that it is not always possible for professional nurses in mental health care ward to come and assist them in managing MHCUs. in general wards, due to shortage of staff, advise them telephonically, leading to delays in provision of care.

The following quotes depict how professional nurses without psychiatric training manage psychiatric patients in general wards:

“…I failed to manage the patient because I did not know how to make her calm from restlessness which was contributing to the elevated blood pressure, I asked the professional nurse in psychiatric ward to come and assist me and I failed, because I was expecting the professional nurse from psychiatric ward to come and show me what I must do, but instead the professional nurse gave me advice telephonically due to shortage and commitments of the ward, which I understand because shortage is everywhere…”Participant 1.

“…Managed to access the phone and ask psychiatric nurses in mental health care ward to assist me as I was afraid, not knowing what to do, all my co-workers in the ward were also afraid. It is then that I knew that the patient has a mental health condition, as the nurse in mental health care ward guided me to go through the previous records of the patient and advised me to report the patient to the doctor who was on standby…”Participant 5.

“… I phoned the mental health care ward, and they advised me on how I should communicate with the patient to make her understand why the injection must be given and also to ask for assistance of hospital security officers in case she keep on refusing…”Participant 7.

Theme 2. Types of patients’ behaviour

Table 3. Theme 2 and sub-themes.

THEME	SUB-THEMES
Types of patients’ behaviour	1.Physical aggression 2. Psychotic behaviour

Table 3. Theme 2 and sub-themes.

THEME	SUB-THEMES
Types of patients’ behaviour	1.Physical aggression 2. Psychotic behaviour

Theme 2. Types of patients’ behaviour

From the data presented in the Table above: theme 2, sub-themes were presented. Two Sub themes out of this theme were identified namely, physical aggression and psychotic behavior. Each is presented below.

• Physical aggression

During interviews, all the participants narrated their experiences in managing mental health care users in a general ward. They indicated that MHCUs. become physically aggressive while admitted in general wards which is difficult for them to manage. They throw a urinal bottle on top of the table, hit nurses with a fist for no reason, hit other patients on the forehead with the plate, they kicked the windows and clap nurses on the face for no reason. The following quotations are what the participants said:

“…We were finalizing the transfer at the nurses’ station when the patient came straight to us holding a urinal bottle, he threw it on top of the table and said, “we don’t do this, how do you take us”, fortunately no-one was injured, the urinal bottle was in plastic material, and it didn’t hit anyone…”Participant 2.

“…I once come across a male patient as I am working in male medical ward who had heart condition and I had to assist him to bath, he hit me with a fist for no reason and I retaliated because I didn’t know why he hit me…”Participant 8.

“…she assaulted fellow patient in her cubicle, she exchanged the plates saying her plate does not have salt and when the other patient tried to explain to her that she must not take her plate, she hit the other patient on the forehead with the plate…”Participant 10.

“…he started by screaming and ran straight to the window not talking, he kicked the window continuously….”Participant 13

“…I once come across a patient as I am working in female medical ward who had heart condition and I have to assist her to move out of her bed, she clapped me on the face for no reason and I retaliated because I didn’t know why she clapped me…”Participant 18.

Berg, Rørtveit & Aase [15], recommend that nurses caring for psychiatric patients should have theory as well as practical management of aggression, violence, and provision of physical safety of psychiatric patients, self, and others.

Similarly, Makgoba [4], revealed that when health care staff feel they are working outside their scope or expertise, they can become frustrated and disempowered resulting in negative consequences for both the patient and the health professional.

Magqadiyane [16], revealed that the area for consideration when working with patients experiencing a mental illness in an acute medical care setting is the challenging behaviours of psychiatric patients who were disruptive, demanding, difficult, non-compliant, aggressive, and agitated, unpredictable, and dangerous.

• Psychotic behavior

During interviews, some of the participants indicated that MHCUs display psychotic behavior through delusions and hallucinations in general wards like, claiming to be the wife of Mandela, very restless, accusing nurses of telling her relatives not to visit them, removing the dressings roughly from the wounds, accusing nurses of going to their homes, refusing their prescribed medication saying it is not their correct one, throwing the pills outside through the window.

The following quotations are what the participants narrated:

“…I came next to this patient, I heard her fellow patient talking with her mentioning her name, she kept quiet, the fellow patient repeated, and she shouted at her saying “I know that you are jealous of me because I am the wife of Mandela …”Participant 12.

“…I once came across a female patient as I am working in female medical ward who had hypertension, the blood pressure was always elevated, and the patient was also very restless…”Participant 9, Participant 11.

“…I was checking on all patients’ documents bed by bed as ward routine, when this patient accused me of telling her relatives not to visit her, I tried to explain to her that I don’t know even a single relative of her, she shouted at me saying “do you know me really? You think I didn’t see you going to my place yesterday” …”Participant 10, Participant 14.

“…The patient was diabetic with burns on his right foot, he became destructive, removing all his dressings on the wound, he was very rough when removing the dressings and the wound was bleeding…”Participant 13, Participant 15, Participant 18.

“…I once come across a female patient as I am working in female medical ward who had epilepsy and I have to give her treatment, she refused saying it is not her correct treatment, I tried to explain but failed, she threw the pills outside through the window…”Participant 16.

4. Discussion

The purpose of the study was to explore and describe the experiences on non-psychiatric professional nurses caring for MCU’s in general hospitals. Data was analysed using Tesch’s eight steps of data analysis and revealed two themes and sub-themes. Themes that emerged were: Managing mental health care users, Types of patient’s behaviour. These themes as well as sub-themes were discussed in detail with direct relevant quotations from the transcripts to enrich the data. The discussion of the literature followed directly and served to confirm the findings. The presentation of findings was done according to themes and were discussed separately.

4.1. Managing Mental Health Care Users

According to Oliveira, Renata; Júnior, Carlos, Furegato and Regina [17], although non-mental health professionals have constant contact with mental health care users, especially non-psychotic patients in their daily clinical practice, their lack of knowledge about mental disorders may prevent them from providing appropriate support to mental health care users.

Similarly, Knight, Bolton and Kopeski [18], expresses the same view by indicating that nursing plays a fundamental role in the mental health area, since well-trained nurses with both theoretical knowledge and practical experience can perform assessments, provide assistance as to clinical and psychosocial aspects of individuals.

Furthermore, Laker, Cella, Callard & Wykes [19], indicate that mental health literacy includes the ability to identify specific disorders, management, or prevention, take appropriate actions when needed to take care of people with mental disorders.

Similarly, Mulaudzi, Mashau, Akinsola, & Murwira [20], also reported that lack of training of nursing professionals to work in the provision of mental health care and the lack of initiative of the institutions to resolve the situation care for psychiatric patient may be compromised.

4.2. Types of Patient’s Behaviour

According to Hamdan and Hamra [21], the most common challenges faced by nurses were their exposure to patients’ unpredictable behaviour, inappropriate behaviour, disruptive behaviour, manipulative, untruthful, violent, and talking to oneself which made patient care very difficult and as a source of disruption to staff, patients and visitors.

This is supported by Cheung, Lee, and Yip [22], who reported that most mental health care users presented with hallucinations, delusional disorders and behavioural problems like manipulation and aggression towards others.

Furthermore, the study by Joubert and Bhagwan [23], reported that nurses experience abnormal behaviour of mental health care users which include demanding special treatment, making insulting remarks, uncooperativeness, aggressiveness, and hostility, not following the prescribed treatment, calling out frequently, and complaining.

Similarly, Hlongwa & Sibiya [24], revealed that symptoms such as agitation, aggression, affective disorder, and sleep disturbance can be difficult to manage and are often exacerbated during an acute admission.

5. Conclusions

The aim of the study was to explore the experiences of professional nurses without psychiatry regarding care of MHCUs in general wards in Limpopo Province. Data revealed that professional nurses without psychiatry in general wards are unable to manage MHCUs independently without seeking assistance from the mental health care ward. Participants further indicated that it is not always possible for professional nurses in a mental health care ward to come and assist them in managing MHCUs in general wards due to shortage of staff, and they advise them telephonically, leading to delays in provision of service. Data also indicated that participants need assistance in caring for MHCUs in general wards because MHCUs are difficult to manage due to their physical aggression and psychotic behaviour. Recommendations are based on the findings of the current study and are directed to the nursing practice and nursing education which include training of non-psychiatric nurses and other categories of nurses in caring for MHCUs in general hospitals, which will lead to improved quality of care of MHCUs in general hospitals.

Author contribution: Conceptualization, V.P.L., and M.E.R.; methodology, N.S.R.; formal analysis, M.M.; investigation, M.M.; resources, N.S.R. and M.E.R.; writing—original draft preparation, V.P.L.; writing—review and editing, M.E.R; visualization, N.S.R.; supervision, M.M. All authors have read and agreed to the published version of the manuscript.