of psychiatric mental health care services into the general health care delivery system in ..... âThey are reluctant to support us in another way, such that you end up with problems like ..... Johannesburg: Rand Afrikaans University. MARSHALL, C ...
Community mental health nurses’ experience of decentralised and integrated psychiatric-mental health care services in the Southern mental health region of Botswana (parti) MK Maphorisa, MCur (Psychiatric Nursing), Rand Afrikaans University M Poggenpoel, PhD (Psychiatric Nursing - Professor), Rand Afrikaans University CPH Myburgh, DEd (Educational Science - Professor), Rand Afrikaans University Abstract
Since the inception o f the decentralisation and integration o f psychiatric m ental health care services into the general health care delivery system in Botsw ana, there has never been a study to investigate w hat com m unity m ental health nurses are experiencing due to the policy. M any o f these nurses have been leaving the scantily staffed m ental health care services in increasing num bers to join other sectors of health or elsew here since the beginning o f the im plem enta tio n o f th e p o lic y . D u rin g th e r e s e a r c h stu d y , phenom enological in-depth interview s w ere conducted with three groups o f 12 com m unity m ental health nurses altogether. An open central question was posed to each group follow ed by probing questions to explore and d e scribe these nurses’ experience of the decentralisation and integration o f psychiatric-m ental health care services. A f ter the data was analysed, related literature was incorpo rated and guidelines for advanced psychiatric nurses were form ulated and described to assist these nurses to cope with the decentralisation and integration o f psychiatricmental health care services. The guidelines w ere set up for the m anagem ent o f the com m unity m ental health nurses who are experiencing obstacles in the quest for mental health w hich also interfere with their capabilities as m ental health care providers.
S edert die ingebruiknem ing van die gedesentraliseerde psigiatriese geestesgesondheidsdienste en die integrasie daarvan in die stelsel van algem ene gesondheidsdienste in Botsw ana is daar nog nooit ‘n studie o f indiepte ondersoek gedoen om te bepaal w at die v erpleegkundiges in die g e m e e n s k a p s g e e s te s g e s o n d h e id s d ie n s te se ondervindings as gevolg van die beleid is nie. Sedert die im plem entering van hierdie regulasie het baie van hierdie v e r p le e g k u n d ig e s d ie sk a m e le p e r s o n e e lk o r p s v an geestesgesondheidsorgdienste verlaat om in ander sektore van die algem ene gesondheidsdienste te werk. G edurende d ie n a v o rs in g s tu d ie is fe n o m e n o lo g ie se , in d ie p te onderhoude gevoer m et drie groepe w at altesam e uit 12 v e r p le e g k u n d ig e s in d ie g e m e e n s k a p s g e e s te s gesondheidsdienste bestaan het. ‘n O op sentrale vraag was aan elke groep gestel. D it was gevolg deur indiepte v ra e om te b e p a a l w at d ie b e le w e n is v an h ie rd ie verpleegkundiges ten opsigte van die desentralisasie en in te g ra s ie v an d ie p s ig ia trie s e g e e s te s g e s o n d h e id s orgdienste is. N adat die data geanaliseer is, is die nodige literatuur ge'inkorporeer en riglyne vir opgeleide psigiatriese v e rp le e g k u n d ig e s g e fo rm u le e r en b e s k ry f o m h u lle behulpsaam te wees om by te bly m et die desentralisasie a s o o k in te g r a s ie v an p s ig ia tr ie s e g e e s te s g e s o n d heidsorgdienste. D ie riglyne is opgestel vir die bestuur v a n d ie v e r p le e g k u n d ig e s in d ie g e m e e n s k a p s g e e ste sg e s o n d h e id sd ie n ste w at ta n s h in d e rn isse en p roblem e ondervind in hulle h o ed an ig h eid as geestesgesondheidsorgvoorsieners.
vices accessable, available and affordable to all people in B otsw ana; and
D ecentralisation and in tegration o f psychiatric-m ental health care services into the general health care delivery system was started in 1980 in Botswana. The introduction of this policy was •
intended to ensure involvem ent o f general health w orkers at all levels to m ake m ental health ser
effective utilisation of the com m unity m ental health nurses such as supervising and giving guidance on mental health to general health workers.
By 1992, m ental health units run by com m unity m ental health nurses had been established and attached to general health
22 Curationis May 2002
facilities all over the country. The World Health O rganisation Publication (1990:36) em phasised that for mental health activi ties to be effective, they should be part o f general health w orkers’ everyday tasks and part o f everyday work in the gen eral health care facilities. N evertheless, a report o f the M ental H ealth W orkshop for Senior M anagers (1993:6) in Botsw ana indicated that one o f the constraints o f m ental health services is lack o f active involvem ent in the m anagem ent o f m entally ill patients by general health workers. In 1993, a deliberate at te m p t to e ffe c t m ore in te g ratio n w as taken to fa c ilita te involvem ent o f general health care w orkers in m ental health services. N urses’ roles in com m unity mental health w ere ex panded to include general nursing functions.
Problem statement Since the policy was im plem ented, the program m e on decen tralisation and integration o f psychiatric-m ental health care services into the general health care delivery system has not been evaluated. Thus, this study looks into the com m unity mental health nurses’ experience of decentralised and integrated psychiatric-m ental health care services.
Since the beginning o f the implementation of the policy in 1993, it seem s to have increased the com munity mental health nurses’ w orkload (M aphorisa 1999: 1-2). In som e places, it seem s to have w ithdraw n them from their area o f interest. M ental health services were placed first, before general health w orkers are ready to participate in m ental health (M aphorisa 1999:2). It seem s that due to this policy, m ore em phasis is put on the involvem ent o f com m unity m ental health nurses in the general health care delivery system w hile the general health w orkers rem ain uninvolved in m ental health, w hereas the Botsw ana Seventh N ational D evelopm ent Plan (1991-1997:378) em pha sises decentralisation and integration o f m ental health care services. This could probably be responsible for the increas ing num bers o f departures o f these scanty and scarce nurses in the m ental health services in Botsw ana (M aphorisa 1999:3). It could appear that these departures are due to dissatisfaction w ith the w ay integration o f this program m e is been run.
Based on the above problem , the objectives o f the study are as follows: •
to explore and describe the com m unity m ental health nurses’ experience of decentralised and integrated psy -chiatric-m ental health care services; and
to describe guidelines that will assist com m unity m en tal health nurses to cope with the decentralisation and integration o f psychiatric-m ental health care services. In this article the first objective o f the study will be addressed.
Meta-theoretical assumptions The researcher will incorporate the Theory for H ealth Prom o tion in Nursing (Rand Afrikaans U niversity, D epartm ent of Nursing, 1999) as a paradigmatic perspective for this research. It endorses a Christian approach. The follow ing param eters o f nursing are also identified: the com m unity mental health nurse, m ental health, environm ent and m ental health nursing.
A com m unity m ental health nurse as a person is believed to be a w hole being who em bodies dim ensions o f body, m ind and spirit and who functions in an integrated, interactive m anner w ith the en v iro n m en t (the in te g rate d m en tal h ealth care services) (Rand A frikaans University, N ursing Departm ent, 1999:4). M ental health nursing is an interactive process where an advanced psychiatric nurse, as a sensitive therapeutic pro fessional, facilitates the prom otion o f clien ts’ m ental health through m obilisation o f resources (Rand Afrikaans University, N ursing D epartm ent, 1999:4). These clients can also include com m unity mental health nurses.
The environm ent includes an internal and external environ ment. The internal environment of the community mental health nurse consists o f body, m ind and spirit. H is/her external environm ent consists o f physical, social and spiritual dim en sions.
M ental health is a dynam ic interactive process. This can also include the community mental health nurse’s environment. This interaction reflects her/his relative m ental health status, which can either contribute to or interfere w ith her/his prom otion o f mental health (Rand Afrikaans University, Nursing Department. 1999:4).
Theoretical assumptions The theoretical m odel used in this research is the Theory for H ealth P rom otion in N ursing (R and A frikaans University, N ursing D epartm ent, 1999). A literature control will be co n ducted after the phenom enological interview s have been ana lysed; thus the researcher will approach the field with no pre conceived fram ew ork of reference.
Methodological assumptions The m ethodological assum ptions, w hich will guide this study, are in line with B otes’ M odel o f Research (1998:1-13). The assum ptions are based on the functional reasoning approach that im plies that nursing research m ust be applicable to im prove nursing practice. The usefulness o f the research in itself provides its trustw orthiness.
Paradigmatic perspective This includes m eta-theoretical, theoretical and m ethodological assum ptions.
In this research, due to its exploratory and descriptive nature, the qualitative m ethod o f research is em ployed.
23 Curationis May 2002
Research design and method Research design The design of this study is qualitative, exploratory, descriptive and contextual in nature (H ollow ay & W heeler, 1996:3-9). Its qualitativeness offers the opportunity to uncover the nature o f the com m unity m ental health nurses’ actions, experiences and perspectives o f w hich is little know n as yet (Glasser, 1992:12). The purpose o f its exploration is to gain a richer understanding o f these nurses’ experiences, w hich are not yet known (Talbot, 1995:90; Mouton, 1996:102; DeVos, 1998:124; Polit & Hungler, 1995:90; Strauss & Corbin, 1990:19). According to B um s and G rove (1993:29), a descriptive study is usually conducted when little is know n about a phenom enon of interest. M outon (1996:133) describes a contextual study as one in which the phenom enon under investigation is studied in term s o f its intrinsic and im m ediate contextual significance.
Research method In-depth phenom enological interview s w ere conducted with three groups o f tw elve com m unity m ental health nurses alto gether. This sample was selected purposively on the basis of the nurses working in m ental health units attached to general health facilities. Sm all groups were used so that each session becam e a dis course in practical reasoning because one story organised around particular concerns, raises confirming or disconfirm ing stories (Benner, 1994:109). O ther purposes o f small group interviews according to Benner (1994:109) are that it: •
creates a natural com m unicative context for telling stories from practice, allow ing participants to talk to one another as they ordinarily do, rather than translat ing their clinical w orld for the researcher;
provides a rich basis for active listening w here more than one listener is trying to understand the story;
Pilot study A pilot study was conducted to test the interview question. T hereafter, the question was corrected.
Phenomenological interviews Phenom enological, in-depth, small group interview s (Benner, 1994:108-109) were conducted and audiotaped with com m u nity m ental health nurses. The researcher asked one central question: “How is it for you as com m unity mental health nurses w orking in these health services?" This w as followed by prob ing questions w hich arose from the respondents’ com m unica tion, that w ere aim ed at getting a clear picture of these n u rses’ experiences. Each interview lasted approxim ately 45 to sixty m inutes. A ccording to M arshall and R ossm an (1989:82) the interviews were much more like conversations than formal struc tured interview s. P articipants’ perspective on the social p h e nom enon o f interest was allowed to unfold as the participants view ed it and not as the researcher observed it. T he groups were instructed to tell their stories directly to each other, to talk as they might do over coffee to ensure active participation and to establish a fam iliar context for narrative accounts (Benner, 1994:109). The w hole group interview ses sion becam e a discourse in w hich one respondent’s story re m inded or revealed to others some aspects of the story and clarified their understanding. D uring the research study, that is, during the establishm ent of rapport, data collection and data analysis, the researcher em ployed “bracketing” by identifying and suspending her ow n assum ptions, beliefs, values, attitudes, experience and k n o w l edge about the phenom enon under study (Talbot, 1995:467; Polit & Hungler, 1995:198) to avoid biases and to understand the inform ant’s experience better. These interviews were taped and transcribed verbatim .
hearing other nurses’ stories creates a forum for think ing and talking about w ork situations.
Follow -up interview s were conducted w ith some o f the partici pants to validate the inform ation gathered about their ex p eri ences.
Data gathering Population and sampling
The sam ple o f this study com prised o f three small groups of com m unity mental health nurses in the Southern m ental health region o f Botsw ana w ho had been w orking in m ental health units attached to general health facilities for at least one year participated in the study. A total o f tw elve com m unity mental health nurses altogether took part; eight fem ale and four male nurses. T heir ages ranged betw een 32 and 50 years. The re spondents had all worked in the integrated m ental health serv ices as com m unity health nurses for at least one year and at the m ost 15 years in the southern m ental health region o f B ot swana. The sam ple was purposively selected from the popula tion (Talbot, 1995:254-255; Polit & Hungler, 1995:235). The sam ple size was determ ined by saturation o f the data on the phe nom enon under study (Talbot, 1995:255) as interview s w ent on. By the end o f interview ing the second group the data was saturated, that is repeating them es yielded.
T hroughout the research study, that is, during the estab lish m ent o f rapport and interviews, fieldnotes concerning the re searcher’s observation (Polit & Hungler, 1995:306); m ethodo logical notes (Wilson, 1993:22; DeVos, 1998:286); and personal notes (Talbot, 1995:478) were written.
Data analysis T he method of data analysis by Tesch in Cresw ell (1994:155) w as used to analyse the tape-recorded d ata after transcription. D uring the data analysis, all the transcriptions were read to get a sense o f the w hole. Ideas were jo tted in the m argin as they cam e to mind. A list o f all topics from all the interview s w ere m ade and sim ilar topics were clustered together. These topics w ere form ed into m ajor topics, unique topics and leftovers. T hey w ere later taken and returned to the data and abbreviated as codes. The codes w ere written next to the appropriate seg m ents o f the text. T he m ost descriptive w ording for the topics w ere found and turned into categories. The list o f categories
24 Curationis May 2002
w as reduced by grouping topics that w ere related. D ata b e longing to each category was assem bled in one place. R ela tionships between m ajor and subcategories were identified and reflected as them es. The identified patterns o f relationships were interpreted in terms o f a social theory as stated by Neuman (1997:426).
T he interpreted them es that em erged in the interview s were discussed with the respondents in the follow -up interview s to verify w ith them that inform ation obtained was representative o f w hat they had meant. The researcher’s data analysis was checked by tw o supervisors who are experts in qualitative re search. A fter the data analysis, conclusions and inferences were made.
Results The results are reflected in Table 1 as them es and categories on com m unity m ental health nurses’ experiences o f decentralised and integrated m ental health care services (M aphorisa, 1999: 38-52). These themes and categories are supported or confirmed by literature control and field notes.
Theme 1: Feelings experienced by community mental health nurses Category: D iscouragem ent related to lack o f appreciation.
Frustration related to rejection, resistance, reluctance or negative attitude o f general health care workers.
T he results o f the research w ere discussed in the light o f re lated literature. No inform ation could be found from studies since there were no studies that dealt specifically with the topic.
D isappointm ent related to general health care w ork ers’ disinterest in m ental health. U nhappiness related to being overw helm ed by work and unco-operativeness o f general health care workers.
Ethical considerations Inform ed w ritten consent w as obtained (Dem ocratic N ursing O rganisation o f South A frica, 1998:3) from all the people in volved (the gatekeepers and respondents). Participation was voluntary. Identity o f interview ees and health facilities were protected by using num bers instead o f nam es to ensure ano nymity (Polit & Hungler, 1995:125;Creswell, 1998:132). Confi dentiality was m aintained to safeguard the respondents’ rights by keeping in confidence the inform ation collected from in formants (Wilson, 1993:253). All audiotapes were deleted after com pletion o f the transcription, data processing and m em ber checking with the participants (D enzin & Lincoln, 1994:212). Com petence o f the researcher was nurtured by two supervisors w ho are experts in qualitative research, as to being m orally ju st and valid (Minichiello, Aroni, Timewell & Alexander 1990:236 244).
Confusion related to being ignored by general health care workers. Theme 2: Surprise related to the feeling that their services are not valued. Theme 3: Loss o f interest in work related to feeling dem or alised, desperate and not recognised.
The m ajor them es that em erged were:
Theme 1: Feelings experienced by community mental health nurses. C ategories under this them e w ere as follow s: •
Trustworthiness Lincoln and G uba’s (1985:290-327) strategies for trustw orthi ness o f findings and interpretation were follow ed. T he re searcher had a long exposure to the research field to establish rapport. Field notes, w hich formed part o f data collection, were w ritten and kept. Triangulation o f the data collection m ethod through interview ing and observation and literature control was done. A dense description o f the data and research process by the researcher provides the required inform ation for other rese arch e rs, should they w ant to prove tran sfe ra b ility in d iffe re n t co n tex ts w ith sim ila r ch aracteristics. M em b er checking was done with one group o f com munity mental health nurses w ho w ere in the sam ple to test data, interpretation and conclusions with the inform ants for correction o f errors and additional inform ation (Polit & Hungler, 1995:362; Talbot, 1995:488; Creswell, 1998: 202). “Bracketing” took place during fieldw ork and the researcher entered the field from a “do not k now ” position.
D iscouragem ent related to lack o f being appreciated by general health workers, especially their im m ediate supervisors and nursing m anagem ent, as described by co m m u n ity m en tal h e a lth n u rses d u rin g the interview as follows:
“It’s very discouraging, especially w hen you provide services that you know they are not appreciated by som ebody w ho is your supervisor.” •
25 Curationis May 2002
Frustration related to rejection o f m ental health re sponsibilities by general health w orkers; reluctance and resistance to change as w ell as negative attitude o f general health w orkers (general nurses, nursing m a n a g e m e n t, a d m in is tr a to r s , a n d m e d ic a l practitioners) towards mental health and mental health services. This is supported by N tebela (1983:11) who states that the M inistry o f H ealth tried to integrate mental health services w ith other services but they m et som e resistance and a negative attitude o f gen eral health w orkers tow ards m ental health, m ental
health services and personnel. T he respondents o f this research described this by saying: “Som etim es when general nurses are posted at the psychiatric unit, we will orientate them on the activities that are supposed to be d o n e ... w hen the non-psychiatric trained supervisor com es around ... to her, it’s som ething th a t... waste o f time ... It’s really frustrating because you are trying to tell this person the right thing. Someone say something from w hat is supposed to happen.”
“We have long been educating our colleagues. They d o n ’t w ant to take it or change.” U znanski (1993:3) states that there is a lack o f interest or a negative attitude tow ards m ental health am ong general health personnel as well as health planners and adm inistrators in countries o f the A frican region. D uring the interview s, the com m unity m ental health nurses said:
“I think that it’s very disappointing because sometim es at m eet ing com m unity health nurses will give report, this one will give report, TB w ill give report. We d o n ’t appear on the agenda anyw here.”
It w as also found that general nurses, general clinic nurses, com m unity m ental health nurses' im m ediate supervisors w ho are not trained in psychiatry, nursing m anagem ent and m edical practitioners disappoint com m unity m ental health nurses by their lack o f interest in m ental health services. The respond ents described this as follows:
“W hen a client com es, they will call you and say ‘Your client is h ere’ or ‘As for this one is for the mental health nurse’. Instead o f them taking a step, okay, and then if it is out o f their scope ... to m aybe consult.”
“T hey are reluctant to support us in another way, such that you end up with problem s like m aybe transport, ... wrong deploym ent, being trapped in an area w here really you are not supposed to be.”
This is supported by a report on M ental H ealth W orkshop for Senior M anagers (1993:6) w hich indicates that as one o f the constraints, general health w orkers are not actively involved in the m anagem ent of mentally ill patients. This is illustrated in the follow ing respondents’ responses:
“Som etim es it’s, it’s really hurting to, to see the negative atti tude o f people tow ards m ental health ... They d on’t see w hat you do. So it m akes us to feel ... let’s say angry or disap pointed and frustrated.”
“In the main hospital ... the nurses and the m edical team ... they ó o n ’t see that they should be involved in seeing, pre scribing and treating psychiatric patients. M edical officers claim that they d o n ’t understand psychiatric patients and they are not trained in the field.”
K gosidintsi (1990:96) states that other general health workers, including som e general practitioners, w ere reported to be negative tow ards any program m e for psychiatric patients. M oreover, Chakalisa (1998:5) indicates that one o f the con straints o f the m ental health situation in Botsw ana is a nega tive attitude to m ental health at all levels o f the health care system. The respondents o f this research described this as follows:
“The nurses in the wards are not w illing to take care o f patient with a history o f confusion.” •
“T hey have no place for psychiatric patients. The fact that she presented with confusion, has a history o f crying ... already is a psychiatric patient. So we try to plead that, ‘Doctor, please can we try having the patient here for some few days?’ ‘No, we don’t have beds, they are preserved for m edical patients, no, we d on’t have beds.” “In our hospital we have m edical officers who have been allo cated to our unit ... as we said that people look down upon psychiatric patients. Though they are allocated, they never ju st go there, ju st to see the patients . . . ” •
D isappointm ent related to general health w orkers’ dis interest in mental health, especially health facility m an agem ent. The study dem onstrated that these nurses are disappointed because m ental health services are not included w hen budgeting and other health activi ties at m anagem ent level are carried out yearly. This is indicated by the respondents in the follow ing re sponse:
U nhappiness related to being overw helm ed by w ork and lack o f co-operation from general health workers, especially m edical practitioners w ho m ake unneces sary referrals and adm issions to m ental health units of people with a history o f mental illness com ing with physical com plaints. This finding is supported by M cConnell, Interbitzin and Pollard (1992:75) who state that although patients w ith chronic m ental ill ness may make frequent visits to w alk-in clinics or em ergency rooms, their physical com plaints may not be taken seriously or thoroughly evaluated. T he re spondents o f this research said in their responses:
“The nurses and the m edical team ... send to us a lot o f refer rals w hich are not supposed to be sent to us ... A nything bordering on psychiatric illness is sent to the psychiatric unit. Psychiatric nurses run up and dow n trying to treat or look after patients that should have been given treatm ent by both the m edical officers and nurses, particularly in the A ccident and E m ergency D epartm ent or on the w ard ... as a resu lt the psychiatric nurses are overw helm ed with a lot o f unnecessary w ork in the unit.” “They refer anything they com e across. So this is clearly unfair on us.”
26 Curationis May 2002
A report on M ental H ealth W orkshop for Senior M anagers (1993:4) illustrates that there were unnecessary referrals and adm issions to psychiatric units for know n m ental patients suf fering from physical illness that end up at the units w ithout being exam ined properly. It was also found that com m unity m ental health nurses in clinics are unhappy because general clinic nurses do not co-operate w ith them w hereas the form er are com pletely involved in all clinic nursing activities. During the interview s, the respondents described this as follow s:
“Since w e are m ultipurpose nurses ... everything is on you. You have to take care o f pregnant or the antenatal, ... general patients, at the sam e tim e this.” “In som e clinics the staff is still reluctant to follow -up p sychi atric clients at their various h o m e s ... So you will see yourself again going around follow ing these patients.”
Confusion related to being ignored by general health workers, especially their supervisors and m anagem ent who do not appreciate their work or their contribution in the health o f people. This is described by the fo l low ing respondent’s response:
“W hen it com es e h ... to the fact that you d on’t get the support or w hatever, you do n ’t ... you ask yourself ... ah ... w hat is h a p p e n in g ? ’ ‘W hat am I doing, is it not appreciated or som ething?” ’
Theme 2: Loss of interest in work related to feeling demoralised, desperate and not being recognised by their supervisors and management who do not even support them. It w as found that com m unity m ental health nurses regret for having chosen m ental health specialisation w hich frustrates them . T he follow ing quotations from the respondents’ re sponses illustrate this:
“It’s quite dem oralising w hen one is trying her or his level best and it’s like people you are w orking w ith do not recognise the good thing you are doing. Because for you to be able to achieve all objectives, you need a lot o f support from the m anagem ent. B ut if they d on’t support you, even the dream s you had, they start going dow n. A nd it’s like you now feel you are no longer interested in your w ork.”
“ ... So very frustrating. A t tim es you feel that if you h av en ’t gone into this service ... this service, at least if you had done m idw ifery, you will functioning very well w ithout problem s. A nd this one is really frustrating.”
Theme 3: Surprise related to the feeling that their services are not valued. T he findings dem onstrated that co m m unity m ental health nurses felt that their services are regarded as unim portant or are looked dow n upon by their supervisors, nursing m anage m ent and authorities in the m inistries. The com m unity m ental health nurses described this in the follow ing responses: “W hen you are walking the patient around, they say ‘Those are the m ad people. Look at w hat they are doing’.. .That’s why it becom es hard w hen it com es to integration o f the services. B ecause nobody value w hat you are doing. H ow can that p erson run the p sy ch iatric services? T hey th in k you are playing.” “I think all these problem s really crop up from the program m e representation, either right from the m anagem ent, m inistry or at the district health team ... B ecause you find that other program m es are being presented. There is the TB coordinator, rehabilitation officer, the district health education officer and there is no representation from the psychiatric services.” The com m unity m ental health nurses perceive their services as being assigned low priority because they are not included in planning committees or budgets. Curran and Harding (1978:75) support this study by stating that since m ental health needs m ay n o t b e re a d ily a p p a re n t to g e n e ra l p u b lic h e a lth professionals and adm inistrators, they tend to assign low p ri ority to the field. The respondents o f the study described this in the follow ing responses: “Even at the M inistry level, they need orientation because it seems that m ental health is not know n in our health sector right from there ... Because it’s like it’s given second seating or w hat.” “This year there is not even a single planned activity on mental health, if you look at our district plan ... It m eans they d o n ’t even regard m ental health as som ething im portant in our life.”
This study dem onstrated that com m unity m ental health nurses w ere surprised that their m ental health services are not valued because o f the way they are neglected by top officials. This is s u p p o r te d by B h a s k a r a (1 9 9 9 :6 9 7 ) w h o s ta te s th a t unfortunately the im portance o f m ental health activities is generally not recognised and tim e and resources are not dedi cated to it. Respondents illustrated this finding in the follow ing responses: “You find that psychiatric nurses end up being deployed com pletely and absorbed and do m ost o f the part w hich is general and not m ental health.”
Limitations The initial central interview question “Tell m e how you experi ence decentralised and integrated psychiatric-m ental health
27 Curationis May 2002
care services” was found to be am biguous because it was ob served during the pilot study that the use o f and perception of the w ord “experience” was varied and misleading. This neces sitated change o f the question to “Tell me how it is for you as com m unity m ental health nurses w orking in these health services” .
A nother shortcom ing encountered was that o f many interrup tions during the interview s, since they were conducted at the respondent’s workplace during working hours. In addition, there was a lot of noise outside the interview room from patients and other nurses as well as from sounding bleepers carried by respondents, that m ade the transcription of audiotapes difficult.
Conclusion This study dem onstrated that com m unity mental health nurses, working in mental health units attached to general health facili ties in the S outhern M ental H ealth region o f B otsw ana, experience unhappiness, frustration, discouragem ent, disap pointm ent, loss o f interest in m ental health work, disbelieve and confusion due to negative attitudes o f their supervisors, managem ent of facilities they w ork under, top authorities in the m inistries, doctors and general nurses towards m ental health, m ental health services and personnel. There were negligible or insignificant positive experiences o f the com m unity m ental health nurses yielded from the study, w hich were badly marred by their m assive negative experiences.
play an im portant part by providing support group therapy for the com m unity m ental health nurses w orking in these decen tralised and integrated mental health care services.
Nursing research Further nursing research based on the identified p at terns o f interactions betw een the internal and external environm ents o f the com m unity m ental health nurses w orking in m ental health units should be conducted, to understand their experiences in a different context like in the northern m ental-health region o f the coun try.
Other mental health professionals C om m unity m ental health nurses interact w ith other health professionals such as m edical practitioners, w ho also affect these nurses’ experiences. M ental health in-service education in the form o f sem inars need to be given regularly to m edical practitioners by p s y c h ia tris ts to re fre sh th e ir m e n tal h e a lth know ledge to enable them to better m anage m ental health problems and develop positive attitudes towards m ental health, m ental health services and personnel.
Recom m endations from the study were made with specific ref erence to nursing practice, education, research and other health professionals.
General nursing curricula should em phasise a holistic approach to patient care. T hat is, it should include m ore psychiatric-m ental health topics to equip gen eral nurses with more information on psychiatric-m en tal health nursing. A much longer period should be given to psychiatric-m ental health clinical practice during general nursing training, to equip general nurses with better psychiatric-m ental health skills and positive attitudes towards mental health, m ental health services and personnel. M ental health nursing in-service education through sem inars or com petency building should be instituted regularly for the general practicing nurses and nursing m anagem ent, to refresh their m ental health and develop positive attitudes tow ards m ental health and m ental health services.
There is a lim ited num ber o f m ental health trained nurses in Botsw ana. These nurses w ork in mental health units and coun cil clinics and need to be utilised properly to make mental health nursing practice m ore effective. The greater part o f their tim e needs to be devoted to training and supervising general health workers, w ho should provide basic m ental health care. The attitu de o f negativity o f g eneral health w orkers (nursing managem ent, supervisors, adm inistrators and top authorities) needs to be addressed by involving them in determ ining and making them aw are o f the negative effects o f the status quo (u n eq u a l d istrib u tio n o f h e a lth reso u rce s, o v erw o rk in g com m unity m ental health nurses, low standards o f m ental health care) to gain their in terest in m ental health. T h eir resistance to this change can be decreased by starting the change process with top officials, by em phasising novel and exciting aspects o f change and by involving them in planning and implementation.
The situation o f m ental health care services in Botsw ana, as depicted by the results o f this research on the experience of the com m unity m ental health nurses o f decentralised and inte grated psychiatric-m ental health care services, show s how dissatisfied these nurse are with the w ay these services are being run. One can imagine the stress they will be going through until the general health w orkers are ultim ately converted to regard th ese services w ith p o sitiv e attitudes. H ence the necessity o f advanced psychiatric nurses to take the responsi bility o f assisting these nurses cope with the decentralisation and integration o f these services, through the use o f guidelines form ulated during this research.
It is clear from the results that com m unity mental health nurses need support from nursing m anagem ent or adm inistrators and im m ediate supervisors. The advanced psychiatric nurses could
B E N N E R , P 1994: Interpretative phenom enology: Em bodi-
28 Curationis May 2002
m ent, caring and ethics in health and illness. London: Sage. B O T E S, AC 1998: A m odel for research in nursing. Johan nesburg: Rand A frikaans University. BO TSW A N A (R E PU B L IC ) 1992: M ental Health Action Plan 1992-1997. Gabarone: Governm ent Printers. B U R N S , N & G R O V E , SK 1993: The practice o f nursing research: C onduct, critique and utilization. 2nd Edition. P hila delphia: W.B. Saunders.
MINICHIELLO, V; ARONI, R; TIME WELL, E & ALEXAN D ER , L. 1990: In-depth interview ing: researching people. M elbourne: Langm an Chester. M O U T O N ,J 1996: U nderstanding social research. Pretoria: J.L. van Schaik. N E U M A N N , W L 1997: Social research methods: Qualitative and quantitative approaches. 3rd edition. Boston: Allyn and Bacon.
C H A K A L ISA , VS 1998: Report on mental health w orkshop for senior health m anagers. G abarone: October, 1998.
N T E B E L A , K 1983: The attitudes o f nurses o f Botsw ana tow ards the m entally ill. University o f Botsw ana. B.Ed. D is sertation.
C R E SW E L L , JW 1994: Research design: Q ualitative and quantitative approaches. London: Sage.
POLIT, D F & HUNGLER, BP 1995: Nursing research: Prin ciples and methods. S"1Edition. Philadelphia: J.B. L ip p in co tt.
C R E SW E L L , JW 1998: Q ualitative inquiry and research de sign and choosing am ong five traditions. California: Sage.
RAND AFRIKAANS UNIVERSITY, 1999: Theory for health prom otion in nursing. Johannesburg: Rand A frikaans U niver sity.
CURRAN, W J& H ARDING , TW 1978: The law and mental h ealth: H arm o n izin g o b jectiv es. G eneva: W orld H ealth O rganisation. D E N O SA 1998: E thical standards for nurse researchers. Pretoria: D em ocratic N ursing O rganisation o f South Africa. D E N Z IN ,N K & LINC O LN, YS 1994: Handbook of qualita tive research. London: Sage. D E V O S, A S 1998: Research at grassroots: A prim er for the caring profession. Pretoria: J.L. van Schaik. G L A SSE R , BG 1992: E m ergence versus forcing: Basics of grounded theory analysis. U nited States o f A m erica: Sociol ogy Press. HOLLOWAY, I & W H EELER , S 1996: Qualitative research for nurses. London: Blackwell. K G O SID IN TSI, AS 1990: The role o f the com m unity mental health nurse in Botsw ana and the problems and needs o f careers o f Schizophrenic clients in the community. University o f Wales C ollege o f M edicine. M aster’s D egree Thesis.
REPORT ON MENTAL HEALTH W ORKSHOP FOR SEN IOR HEALTH MANAGERS: (3ri: 3-10 August 1993: Lobatse). STR A U SS, A & C O R BIN , J 1990: Basics o f qualitative research: G rounded theory, procedures and techniques. L on don: Sage. TALBOT, LA 1995: Principles and practice o f nursing re search. London: M osby .
U ZN A NSK I, A 1993: Progress in the implem entation o f com m unity m ental health services in countries o f A frican region. Geneva: M HH/AFRO 11 May 1993. W IL SO N , HS 1993: Introducing research in nursing. Edition. N ew York: A ddison-W esley Nursing.
W O R LD HEALTH ORGANIZATION, 1990: The introduc tion o f m ental health com ponents into prim ary health care. Geneva: W orld H ealth Organisation.
L IN C O L N , YS & G U BA , EG 1985: N aturalistic inquiry. Beverly Hills: Sage.
M A PH O R ISA , M K . 1999: Com m unity mental health nurses’ experience o f decentralised and integrated psychiatric m ental health services in the S outhern M ental H ealth R egion o f B otsw ana. M C ur - Psychiatric N ursing M ini-dissertation. Johannesburg: Rand A frikaans University. M ARSH ALL, C & ROSSM AN, GB 1989: Designing qualita tive research. London: Sage. M cC o n n e l l , s d ; i n d e r b i t z i n , l b & p o l l a r d , w e 1992: Prim ary health care in the com m unity m ental health care: A role for the nurse practitioner. A Journal for the Am erican Psychiatric Association. 43 (pp. 7-12) 1992.
29 Curationis May 2002