Primary health care nurses’ management practices of common mental health conditions in KwaZulu-Natal, South Africa

Background Psychiatric conditions contribute to 13% of the global burden of diseases and account for one third of years lost because of disability (YLD). Despite the high prevalence of mental health problems, primary health care (PHC) services remain ineffective in managing patients with mental health conditions. Objectives The aim of the study was to determine the practices of PHC nurses in the management of psychiatric patients in primary health care clinics in one of the rural districts in South Africa. Method A survey was conducted amongst nurses working in several PHC clinics in KwaZulu-Natal (KZN) in order to determine their practices in the management of psychiatric patients. Mixed methods were used to determine the PHC nurses practices in the management of psychiatric patients. Results The findings revealed that in five sites (83.3%) treatments are not reviewed every six months, there were no local protocols on the administration of psychiatric emergency drugs, and none of the study sites provided psychiatric patients with education on their medication and its possible side effects. Conclusion Based on the results of this study it is evident that psychiatric patients at PHC clinics in the district where the study was conducted do not receive quality treatment according to institutional mental health guidelines.


Introduction
• Remember the person, meaning that any medical intervention should be made with the person as a whole in mind. • Keep the treatment regimen simple so as to improve patient acceptability and adherence. • Begin low, go slow, but reach high and long, meaning that the right dose of medication should be used for the correct duration. • Antidepressants can be good for patients with any of the 10 common psychiatric diseases, such as schizophrenia, major depression and generalised anxiety disorder. • Monitor side effects carefully. • Consult when it is necessary (National Department of Health 2006).
However, despite the release of these guidelines, gaps still exist in the management of psychiatric patients in PHC clinics (Petersen et al. 2012) as de-institutionalisation was introduced without the necessary community based services, especially in rural areas (Department of Health 2013b). Petersen et al. maintain that psychosocial rehabilitation programmes are not provided in rural clinics, there is insufficient support for PHC clinic nurses in the management of psychiatric patients and poor identification and treatment of common mental disorders persist (Petersen et al. 2012). PHC services prioritise the control of chronic diseases that decrease life expectancy above diseases that cause disability (Grandes et al. 2011). Failure to diagnose mental health conditions may increase the rate of healthcare service utilisation (WHO 2008b).
Some psychiatric patients require continuity of care. They get psychiatric treatment every month from the PHC clinic and are reliant on the nurses who deliver the care. As a result of staff shortages in some PHC clinics, patients may be attended to by a registered nurse who has had no psychiatric training (Lund et al. 2008). The danger of this practice is that such nurses may misdiagnose a relapse in mental illness because of a lack of knowledge (Mwape et al. 2010).

Problem statement
The National Mental Health Summit held on 12 and 13 April 2012 in Ekurhuleni, South Africa, was attended by representatives from government departments, nongovernmental, research and user organisations, the WHO, academic institutions, professional bodies, traditional health practitioners, and clinicians. The Ekurhuleni Declaration on Mental Health (2012) that emanated during the summit concluded that integrating mental health services into primary health care, which is the foundation of the health care system, would increase prevention, screening, selfcare, treatment and rehabilitation of patients with mental disorders and thus reduce the number of psychiatric patients referred for secondary and tertiary health care services. Even before the summit PHC nurses have been responsible for promoting mental health, detecting and treating people with common mental health conditions, ensuring an efficient referral system for patients requiring specialist care (Saxena et al. 2006) and providing follow-up treatment for patients who are stable (Petersen et al. 2009).
However, despite the strategies set out above, mental health in South African PHC clinics has a low priority and people with mental health disorders do not receive the care they deserve (Draper et al. 2009;Williams et al. 2008). Studies have found that nurses in PHC clinics are poor at detecting and managing mental health conditions (Naledi, Barron & Schneider 2011) and are not delivering psychosocial rehabilitation programmes, especially in rural clinics (Petersen et al. 2012).
There is shortage of human resources in PHC clinics which impacts negatively on integration of mental health into PHC. Awenva et al. (2010)

Significance of the study
Lack of support, training and supervision of health care providers to provide quality mental health care have been identified as contributing factors for poor detection of mental health conditions and poor management of people with mental health conditions (Naledi et al. 2011). As no previous studies have been conducted to investigate PHC nurses' management of psychiatric clients in the context under study, the results of this study may contribute to improving the quality of care provided to people suffering from mental health conditions.

Objective
The aim of the study was to determine the practices of PHC nurses in the management of psychiatric clients in PHC clinics in one of the rural districts in South Africa.

Research question
The research question was: 'What practices are adopted and implemented by PHC nurses in the management of psychiatric clients at PHC clinics in one of the rural districts in South Africa?

Research method and design
A survey was conducted amongst nurses working in PHC clinics in a rural district in South Africa in order to determine their practices in the management of psychiatric patients. Mixed methods were used. For the qualitative aspect, semistructured interviews, using an interview schedule with open questions, were conducted with PHC nurses. For the quantitative aspect, a questionnaire was used that included principles of supervision policy, which are continuity and accessibility.
Whilst some management issues were explored, the seven principles of the Standard Treatment Guidelines for Common Mental Health Conditions served as the basis for both the interviews and the questionnaire. However, principles 3 and 5 were excluded as nurses do not prescribe medication. Principle 4 was included because nurses monitor medication use and distribute the medication (see Table 1).

Setting
The study was conducted in uThungulu Health District in the northern area of KwaZulu-Natal. This is the third largest district in the province with a population of 979 513, which is composed of Africans, white people and Asians (Department of Health 2013b). UThungulu district was selected as the site of the study because it represents a semi-urban and rural scenario (see Table 2).

Population and sampling
All clinics selected were public institutions providing the full PHC package as prescribed by the National Department of Health. The clinics were under the supervision of the hospitals attached to them in accordance with government recommendations that they be visited once a month by a PHC supervisor for mentoring and guidance (National Department of Health 2009). However, as a result of poor terrain which makes it difficult for the PHC supervisor to access them, the supervision rate for clinics in deep rural areas is 60%, which is far below the norm of 100% (Department of Health 2014a).
Whilst some clinics are semi-urban and therefore easily accessible, others are more rural, situated outside of towns or cities, where there is poor infrastructure. Those which are deep rural are at least 200 km away from urban areas and have extremely limited infrastructure and human resources (Department of Health 2014b). There were no urban areas in the health district in which the study was carried out.
Each clinic was visited on a separate date and had been advised of the visit. Convenient sampling was used whereby the researcher invited the health care workers present at the clinic to participate in the study. All health care workers were included, also those who were not registered as psychiatric nurses because it is possible that they would have to manage mental health patients because of limited staff. The sample therefore consisted of PHC nurses and staff nurses who were available during the visits.
The registered nurses in charge of the clinics (clinic managers) were purposely selected to complete the questionnaires as it required a self-report from them. Only 10 professional nurses and 5 staff nurses from six study sites from a total of 32 professional nurses and 15 staff nurses allocated to these clinics participated in the study as they were the only category of staff available during data collection at the clinics. Interviews were audio recorded for later transcription with participants consent.
Section three of the questionnaire involved reviewing patient records at the clinics. The criterion for inclusion of records was that the patient had to have been attending the clinic for three consecutive months without interruption. Records were randomly selected, and 110 of 415 met the criterion for inclusion. Entries in patients' medical records were reviewed to assess the following: • If patients' medication had been reviewed in the six months prior to the study. • If patients had been assessed before they were given treatment. • If patients had been given education on their medication and possible side effects. • If a medical examination had been conducted in the two years prior to the study.  Clear documentation was given a score of 1 and absence of data was scored 0. The average service utilisation for the clinics for three months, from October 2011 to December 2011 was noted.

Research method and design Data collection process
The following instruments were used to collect data on the practices of PHC nurses in the management of psychiatric patients in primary health care clinics in one of the rural districts in South Africa: • A questionnaire: The questionnaire was adapted from the PHC Supervision Manual for the purpose of collecting quantitative data from the registered nurse in charge (clinic manager) at each of the selected PHC clinics on the manner in which mental health conditions were managed at the particular clinic. The questionnaire had five sections with 24 items, 19 of which addressed the implementation practices in the management of psychiatric patients in PHC clinics. For the 19 items see Table 3. • Record review: Section three of the questionnaire involved reviewing the previous three months' clinical information recorded on clinic-held patients' records. There were five items which addressed the clinical quality of mental health care provision to psychiatric patients. • Interviews: An interview schedule with five semistructured questions was used to collect data on the management practices of PHC nurses to determine how psychiatric clients were being managed.
The researcher collected the data, transcribed the recordings and analysed the data.

Data analysis
Quantitative data were analysed according to simple descriptive analysis. Data were entered in the computer and analysed using SPSS (version 19) for Windows (spss-t2). A cross tabulation of the record review was carried out in order to ascertain whether there was any relationship between the geographical area and the management of the psychiatric patients.
Qualitative data were generated from the audio-recorded interviews by transcribing the interviews verbatim. Thematic analysis was used because of its benefit of flexibility (Braun & Clarke 2006). The researcher used Braun and Clarke's guide to the six phases of conducting thematic analysis which are: becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.

Ethical considerations
Ethical permission was sought from the University of KwaZulu-Natal Research Ethics Committee (reference number HSS/0653/011D) and from the KwaZulu-Natal Department of Health. Permission was also sought from uThungulu District Office Management and from the Chief Executive Officer of the hospital to which the clinics were attached. Participants were informed about the study and informed consent was obtained at the start of each clinic visit. Participants were informed that participation in the research project was voluntary. They were advised of the confidentiality and anonymity of their responses and that they could withdraw at any time without prejudice. The researcher conducted the interviews personally and ensured that the participants were at ease. A time for reflection was provided after the interview session.
Names for the interviewees were not used at any time. The responses from registered nurses were labeled as 'RN1' to 'RN10' and responses from staff nurses were labeled as 'EN1' to 'EN5'. Data were coded by an independent coder to ensure trustworthiness.

Reliability and validity
Data were triangulated from three data sources in order to facilitate comparative analysis of participants' responses. This was carried out to ensure validity of the findings by cross checking the quantitative data with the qualitative data (Wilson 2014). Pattern matching was then performed in order to ensure internal validity (Voss, Tsikriktsis & Frohlich 2002).

Results and discussion
Results from the questionnaire are summarised in Table 4 and the findings from the record review are summarised in Table 5.

Demographic information of nurses who completed the questionnaire
Six female registered nurses in charge of the six clinics completed the questionnaire. Three of the registered nurses were aged between 51 and 60 years, one was between the ages of 31 and 40 and one between the ages of 41 and 50. Two of the nurses had a four year nursing diploma, one had a diploma in psychiatric nursing and three had general nursing only.

Demographic profile of nurses who took part in the interviews
Interviews were conducted with 10 registered nurses and 5 staff nurses. All nurses who took part in the interviews were female. One registered nurse was aged between 51 and 60 years and had a qualification in General Nursing with Psychiatric Nursing; four were between 41 and 50 years, two of whom had a qualification in General Nursing with Psychiatric Nursing and two had completed a four year Diploma in Nursing; and five were between 21 and 30 years and had a four year Diploma in Nursing. One staff nurse was aged between 51 and 60 years, one was between 31 and 40 and three between 21 and 30 (see Table 3).

Demographic profile of record review
The 110 records reviewed revealed that the highest percentage (97.4%) of patients was treated in rural clinics as compared to semi-urban (1.8%) and deep rural areas (0.9%). Most patients from semi-urban (n = 36) and rural (n = 38) study sites were single. Statistics showed no significant difference in unemployment rate between semi-urban (n = 38) and rural areas (n = 41). The educational status was low in deep rural areas, with 21% of participants being recorded as having no education (see Table 5).

Findings from the questionnaire
The findings revealed that policies and guidelines on the Mental Health Care Act (17 of 2002) were not available in 66.7% of the clinics surveyed. Participants indicated that patients in emotional crisis, patients requiring counselling and patients referred from hospitals were attended to daily in all the study sites.
Written referral criteria and routes were not available in any of the study sites and a client in a current crisis could not receive continuity of care from the same practitioner. People with symptoms of mental illness were not given a full physical examination, including an examination of the neurological system, blood glucose tests and assessment for signs of substance abuse. Medication was available to patients as on the PHC Essential Drug List (EDL) and routine monitoring of drug levels was carried out in all study sites. Sixty seven percent of study sites did not have support groups for people with mental health conditions. Feedback informing the PHC facilities of their role in continuation of care was only received by 66.7% of the clinics.

Results from interviews
Themes relating to the practices of PHC nurses were generated based on the interview schedule that was used to collect data. The results are reported according to the themes.  Data from the survey and the record review have also been integrated into each theme.

Theme 1: Treatment begins with diagnosis
During interviews nurses indicated that psychiatric patients are given a full physical examination, including blood glucose tests as evident in the excerpt below: 'We also assess them the mental symbol whether he is well oriented, is he relapsing, some of them are having fits, assess how often do the fits occurred, how are they, how do they look. Are they oriented, are they responding or not responding.' (RN1) This was not consistent with the findings of the document review which indicated that people with symptoms of mental illness had not been given a full physical examination which included the neurological system, blood glucose tests and assessment for signs of substance abuse in any of the study sites (Table 4).
Findings revealed that in-depth interviews had not been held with patients at two month intervals as prescribed, but that critical information had been evaluated when the patient came to collect treatment. This was confirmed by one of the nurses who said: 'Though it is a summary but you do that general appearance of a client, do orientation, memory as you remember [RN1]. But I have always seen summary being done.' (RN5)

Theme 2: Remember the person
Participants indicated that patients who are seen to be restless in the queue are attended to first: 'We do fast-track those we know cannot wait.' (RN5) In some clinics, interviewees indicated that patients are treated with courtesy by greeting them before they are attended to.

Theme 3: Medication dose as low as possible
In 98.2% of the cases, the record review revealed that medicine required by the psychiatric patients had not been reviewed in the six months prior to the study (Table 5). It was observed in the patients' records that some patients were receiving the same treatment that had been prescribed six years previously. There was no evidence whether patients had been given education about their treatment in the six months prior to the study.

Theme 4: Monitor side effects
Nurses in all study sites indicated that they take blood samples from patients whose drug levels need monitoring. This was confirmed during the interviews: 'Bloods are taken in six months and they then go to the doctor.' (RN6) Whilst emergency treatment for side effects was available in five of the study sites, it was not available in one site.

Theme 5: Consult when necessary
Referral criteria and routes were not available in the clinics where the study was conducted and it is therefore not clear what procedures are followed when PHC nurses refer patients to the next level of care. During interviews participants indicated that they refer patients who are due for treatment review and monitoring of lithium levels. They also indicated that they consult the psychiatric trained nurse who is based at the hospital psychiatric clinic when they are not sure of what to do: Nurses indicated that they also consult other stakeholders, such as police officers, if they are faced with a patient who is violent. Patients with a first episode of mental illness and patients who show signs of aggression are transported to the hospital with the help of police officers, if necessary: 'If a new patient coming from home telling us that she has delusions for the first time, we first check whether she is on any treatment. If he is too violent, we give him injection so that he becomes calm and we call an ambulance. If he becomes way beyond the ambulance we call the police and they do respond.' (RN1) Theme 6: Continuity of care Table 4 shows that nurses in all six study sites indicated that it is impossible for a patient in crisis to receive continuity of care from the same practitioner. This was affirmed by one of the nurses who said: 'It's not one sister who attends to them. It's like daily allocation. If I am not in someone else do attend to them …' (RN1) To ensure continuity of care, nurses recommended that: 'There must be a person who must be solely responsible for them so that she can even attend workshops and be updated with new things that are happening in psych.' (RN3).
Nurses in four of the sites (66.7%) indicated that continuity of care is a challenge because they do not receive feedback when a patient has been referred to hospital.

Theme 7: Accessibility of care
Nurses at all the study sites reported that services for people in emotional crises and those requiring counseling were available on a daily basis as well as services for psychiatric patients who had been referred to PHC from hospital. However, services for psychiatric patients were only available daily in four of the sites (66.7%). Patients attending the other two sites (33.3%) were seen by a psychiatrically trained nurse on a dedicated day once a month. One of the interviewees said: 'When they come to the clinic, they come in groups. We attend to them in the morning when they come. We have a nurse who attends to them every first Friday of the month.' (RN) The participant added, however, that if the dedicated registered nurse is off duty on that day, another professional nurse is allocated to attend to patients: '… But if I am not in someone else do attend to them.' (RN) In the clinics where services are available on a daily basis, patients join the general queue and are seen by the registered nurse who happens to be on duty on that day: 'They are attended by the sister who is available. If we see there is a problem, we refer.' (RN10) This is consistent with the findings of the questionnaire where the nurses in charge at all study sites (100%) indicated that patients are seen by whichever nurse is on duty on the day rather than by the same nurse on subsequent visits (Table 4). Participants indicated that psychiatric patients are promptly attended to if they become restless whilst in the queue: 'There are two or three clients who do not want to sit down. So you just check them and not make him to wait.' (RN5)

Theme 8: Management of care
The findings revealed that mental health guidelines, including the Mental Health Care Act (17 of 2002), were not available in four of the study sites (66.7%). Furthermore, five (83%) of the study sites were not visited by the mental health team. Only one site reported being visited once a month by the mental health team from the mother hospital.
Records of attendance to enable tracing of patients defaulting treatment were not available in four sites (66.7%). Nurses put the blame on the system for introducing integration of service: 'Since the integration of mental health was implemented, and it was said the clinic must be every day, Aii!, you see that is where we started to have defaulters.' (RN6) They expressed that it was not easy to identify patients who had not come for treatment: 'Like now as they are coming at any time, you are not able to see who has come, who has not come. If you have specific day you will know that you have seen all 10 patients.' (RN8).
There were no local protocols on the administration of emergency psychiatric drugs in five of the sites (83.3%). Moreover, none of the study sites had support groups for psychiatric patients and their families or referral protocols. One of the interviewees acknowledged the fact that they are not managing the psychiatric patients properly by saying, 'We have not been well established in attending to them the correct way. But we have just started to take care of them' (RN1).

Theme 9: Problems impacting on quality mental health provision
In four of the study sites (66.7%) staff had received in-service education provided by the mother hospital, but none of the study sites had programmes of in-service training on mental health planned for the year. This was consistent with the findings of the interviews where some of the nurses indicated that they needed in-service education: 'But we need a person who will update us and tell us what is expected so that patients can get total nursing care. Most of the nurses last have the information during their training and we are not sure what to do.' (RN2) Nurses indicated that they do not provide quality mental health because they experience shortages of staff: 'Due to shortage of resources, we tend to do things routinely. We summarise as I have just said that we are now doing summary.' (RN5)

Discussion
The study explored the practices used in the management of psychiatric clients at selected PHC clinics by looking whether PHC nurses implemented the principles of the Standard Treatment Guidelines for Common Mental Health Conditions. The discussion is in accordance with the principles.

Principle 1: Treatment begins with diagnosis
Although psychiatric patients should be given a full physical examination which includes assessment of the neurological system, blood glucose and signs of substance abuse before a diagnosis are made, the results revealed no evidence that any thorough assessment or any psychosocial interventions were being implemented. This could be attributed to PHC nurses' lack of knowledge and skills with respect to psychiatric patients, or, as in a study conducted by Petersen et al. (2009) where nurses verbalised that assessing a psychiatric patient needs extra time.
None of the study sites had a programme for in-service training on mental health although such training would enable PHC nurses to provide quality mental health care and thus meet the medical and psychological needs of the patients (Collins et al. 2010). Saraceno et al. (2007) recommend that nurses in PHC facilities be provided with training in mental health to enable them to assess and treat mental health problems.
Training and capacity building of PHC nurses must be an ongoing process because new nurses who have not been trained in mental health are continually being allocated to PHC facilities. The PHC clinics have a duty to establish support groups for psychiatric patients and their families, but it was found that there were no support groups for psychiatric patients and their families in any of the sites. Offori-Atta, Read and Lund (2010) are of the opinion that support groups would assist families in caring for their family members suffering from mental health conditions.

Principle 3: Start medication dose as low as possible
The patients' treatment was not monitored. For a person with a psychiatric condition, the need to take medication for a long time may affect compliance (Serobatse, Du Plessis & Koen 2014).

Principle 4: Antidepressants for treatment of anxiety
This principle was excluded as nurses do not prescribe medication and treatment for newly diagnosed patients it is prescribed by the doctor.

Principle 5: Monitor side effects
Side effects were not monitored by nurses (Table 4) and education on side effects was not given. This is consistent with the findings of the study conducted by Hetrick et al. (2011) who found that nurses only became aware that patients were experiencing side effects if this was brought to their attention by these patients. The care provided at the clinics seems to be dictated by routine, based only on providing medication.

Principle 6: Consult when necessary
Findings revealed that nurses did seek advice when they need guidance in the management of psychiatric patients, but this consultation was not guided by any criteria. PHC nurses are not responsible for initiating treatment (Petersen et al. 2009).

Principal 7: Continuity of care
Findings showed that there were variations on how psychiatric patients were being managed in the different study sites. In some clinics, services for psychiatric patients were offered daily, whilst in others, services were only offered once a month on a dedicated day. Patients attending the clinics which offer a daily service joined the general queue and were seen by whichever nurse was on duty at the time. There is, therefore, no continuity of care. Clients, health care workers and policy makers consider continuity care as an effective strategy in the management of long term psychiatric disorders (Burns et al. 2009). The findings of the study conducted by Green et al. (2008) revealed that continuity of care was associated with good recovery and better quality of life.

Limitations of the study
One of the limitations identified in this study was that it did not investigate whether the patients were satisfied with the service they received from the study sites. According to Westaway et al. (2003), a satisfied patient is free to utilise the health service and comply with the treatment plan. They advise that patient satisfaction can be measured by getting to know the patients' experiences regarding health care.

Recommendations
The researcher recommends that PHC mental health services should be scaled up by offering services that are based on scientific evidence and by adhering to available mental health guidelines and protocols (Eaton et al. 2011). Psychosocial rehabilitation at clinic level should be strengthened to ensure that psychiatric patients are managed holistically (Petersen et al. 2009).
It is also recommended that mental health care in primary health care clinics be revived through retraining of PHC nurses on mental health care. Mentoring and supervision of PHC nurses should be carried out so that they provide quality mental health services (Saraceno et al. 2007). In terms of improving the mental health care, it is recommended that support groups for psychiatric patients and their relatives be established because they not only provide a recovery-oriented treatment that is not provided through medication, but also help to reduce stigma (Goldstrom et al. 2006). Psychosocial rehabilitation programmes should be implemented in PHC clinics as part of management of psychiatric patients (Petersen et al. 2012).

Conclusion
Based on the findings of the study, it is evident that psychiatric patients do not receive the quality mental health services they deserve. The study identified a lack of knowledge and skills amongst PHC nurses as contributing factors to the poor management of psychiatric patients in the study sites. Staff shortages in PHC clinics are a barrier towards provision of quality mental health care, especially in rural clinics because these clinics are overburdened with multiple programmes and high patient workloads (Sareceno et al. 2007). It became apparent that principles 1 (assessment), 4 (lowest dose) and 6 (management of side effects) are not being adhered to in PHC clinics. This is the result of both a lack of adequate preparation of the nurses doing the work, lack of support by other health care providers, such as psychiatrists, as well as the lack of adequate guidance on the guidelines provided.