The Role of the Community Mental Health Nurse in Botswana: the Needs and Problems of Carers of Schizophrenic Clients in the Community

The purpose of this study was to identify and describe the role of the psychiatric/community mental health nurse in the context of primary health care in which mental health is an integral part of the general health care system and in a specific socioeconomic background. Nine (9) community mental health nurses who graduated from a local training program for community mental health nurses at post basic level, twenty five (25) carers responsible for daily care and welfare of schizophrenic clients from rural, semi-rural, urban and semi-urban areas country wide participated in the snidy. T h e s tu d y w as e x p lo ra to r y and b oth qualitative and quantitative data was collected using semi structured interviews, unstructured observation and documentary search methods were used. Data analysis for both qualitative and quantitative data was done through simple frequency counts. findings indicated that the community mental health nurse's role was mainly technical with three main functions. • Mental Status Assessments of Clients • Prescribing Treatment and • A dm inistration o f T reatm ent through injection and other routes. Carers complained of inadequate care and support from nurses, social and economical burdens of caring for clients in the community and an e x p re s s e d n e e d fo r p e rio d ic re-admission of chronic clients to hospital and rehabilitation services for discharged patients in the community. The study concluded that, the role of the community mental health nurse is more than just the technical activities identified. It is highly dependent on, the availability of resources, characteristics of clients and care givers in the com m unity and the nurses professional preparation which is vital in providing him/her with the confidence to o bjectiv ely evaluate ch anges occurring a ro u n d h im /h e r an d m a k e n e c e s s a ry judgements and adjustments in her role. The community approach to mental health in Botswana began in 1977 commencing widi a pilot project in which an outpatient clinic was set up in one of the health centres. A psychiatric nurse was assigned to run the clinic (M.O.H 1984). When the pilot project proved successful, five other psychiatric nurses were assigned to establish psychiatric units in strategically located hospitals and health centres around the country. …


A Kgosidintsi
The purpose of this study was to identify and describe the role of the psychiatric/community mental health nurse in the context of primary health care in which mental health is an integral part of the general health care system and in a specific socio-economic background.Nine (9) community mental health nurses who graduated from a local training program for community mental health nurses at post basic level, twenty five (25) carers responsible for daily care and welfare of schizophrenic clients from rural, semi-rural, urban and semi-urban areas country wide participated in the snidy.T h e s tu d y w as e x p lo ra to r y and b oth qualitative and quantitative data was collected using semi structured interviews, unstructured observation and documentary search methods were used.Data analysis for both qualitative and quantitative data was done through simple frequency counts.findings indicated that the community mental health nurse's role was mainly technical with three main functions.

• Mental Status Assessments of Clients
• Prescribing Treatment and • A dm inistration o f T reatm ent through injection and other routes.
Carers complained of inadequate care and support from nurses, social and economical burdens of caring for clients in the community and an e x p re s s e d n e e d fo r p e rio d ic re-admission of chronic clients to hospital and rehabilitation services for discharged patients in the community.
The study concluded that, the role of the community mental health nurse is more than just the technical activities identified.It is highly dependent on, the availability of resources, characteristics of clients and care givers in the com m unity and the nurses professional preparation which is vital in providing him/her with the confidence to o bjectiv ely evaluate ch anges occurring a ro u n d h im /h e r an d m a k e n e c e s s a ry judgements and adjustments in her role.
The community approach to mental health in Botswana began in 1977 commencing widi a pilot project in which an outpatient clinic was set up in one of the health centres.A psychiatric nurse was assigned to run the clinic (M.O.H 1984).When the pilot project proved successful, five other psychiatric nurses were assigned to establish psychiatric units in strategically located hospitals and health centres around the country.An out patient was also established in the country's only mental hospital.
The program was built around the existing group of psychiatric nurses and the only psychiatrist in the country.All the nurses and the psychiatrist were trained outside the country in institutionally based training programs.No additional staff were available.
The community based mental health care movement sought to enable most patients identified as suffering from psychiatric disorders to receive care and treatment within their communities, to increase the availability of services and to initiate preventive activities.
The thrust of the program was to make the services community based as opposed to the custodial care that had been practised since 1938.Community resources such as the extended family, clergymen, village elders, both governmental and non-governmental organizations were mobilized to participate in the care of the mentally ill in the community and refer to the psychiatric personnel those that became unmanageable in the community, (Ben-Tovim 1987).

S TA T E M E N T O F T H E PR O B L E M
As accessibility of the psychiatric services increased, so did the utilization of services.
Figures from the registers kept in all the psychiatric units showed that whilst the referrals increased only modestly, the number of repeat consultations increased six fold.(Bentovim 1987 p. 192).Although coverage of mental health services had improved since the community based psychiatric service was launched, its quality was hard to measure.A visiting W.H.O consultant remarked that curative skills and skills in interviewing, communication, counselling, behaviour and relaxation therapies were lacking among both the psychiatric educators and nurses running the psychiatric units.(German 1984).
The post basic mental health nursing outcome objectives were spelt out as follows; • To prepare a nurse to render preventive prom otive curative and rehabilitative se rv ic es to co m m u n ities in h is/h e r catchment area with minimum time spent in the unit.
• S upervise and teach h ealth w orkers participating in the delivery of mental health care.
• S u p p o rt and p a rta k e in co m m u n ity activities and coordinate all mental health p ro je c ts in c o lla b o r a tio n w ith th e psychiatrist in charge.
Literature indicates that the role o f the psychiatric/community mental health nurse is influenced by a number of factors such as:- • The socio-cultural and economic situation where they work.
• The authoritarian system of care designed to show that nursing functions are a response to physicians' judgements and orders.
• S elf co n fid en ce b u ilt on the strong educational background which is vital to allow the nurse to evaluate changes around her and make necessary judgements and adjustments to function as an independent practitioner with minimum reference to the psychiatrist.
• The attitudes that prevail among colleagues and other health professions and those of the clients and carers.
The psychotherapeutic and medical treatment skills of the community mental nurse had been questioned (Wankiri 1984 German 1986).The educational preparation had been found to be appropriate for hospital oriented personnel and a recommendation was made to emphasise skills pertinent to the nurses work as described in the curriculum to allow him/her to fimction au tonom ously in the com m unity based program.
T h e p r e v a ilin g a ttitu d e s am ong the com m unity m ental health nurses, their colleagues, and medical professionals which were developed from institutionally based training based on the disease model.This influenced the nurse in psychiatric training towards a curative model of care.
The communities had been medicalised over the years and made to believe that mental illness could only be treated in instimtions and they demanded a curative community service.
The effect of urbanization in the family structure was characterised by migration of the productive age group to urban areas to seek g ain fu l em ploym ent thus reducing the extended fam ily structure.This in turn reduced the family's ability to care for the sick m em ber and its capacity to m aintain a mentally ill dependent adult.Carers were defined as anyone providing daily care for a cUent diagnosed as schizophrenic.
Carers were identified from the clinic registers and followed to their homes with the help of the community mental health nurse.
Carers must have been living with the client for over eight weeks prior to the study and have been visited at least once by the nurse during this period.The actual period of care ranged from a year to several years.
At least three families from each area where the community mental health nurse was based.

□ D ata Collection:
Face to face semi-structured interviews of unlimited time depending on the willingness of the participant to respond to questions were conducted for both the nurses and carers.
Non-participant observations were made of nurses activities for the rest of the day and relevant nursing records including work plans and nursing notes were studied.Observation of interaction between the nurse and carers was observed during home visits.
□ D ata Analysis: Interviews were tape recorded.Analysis basic themes shared by study sample and simple frequency counts were made.

FIN D IN G S
The role activities of the community mental health/psychiatric nurse.For the purpose of the study, community mental health/psychiatric nursing was considered a component of the whole field of nursing.Entry qualifications to post basic training require that one be a general nurse.Activities were categorised as follows in order of highest ranking: 1.It could be inferred from the fmdings that the la rg e c a tc h m e n t are a w hich th e o nly Psychiatric Mental Health Nurse had to cover acted as a limiting factor with regard to the variety of services she provided to the cUents.It is also possible that her professional preparation could have had an influence.The curriculum she had gone through did not prepare her for a community based program.
The Nurses have to be sure of what nursing is to be able to manage the factors influencing their practice.
Although no conclusions can be drawn from these fmdings, they raise a lot of questions to be researched upon.
□ Needs and Problems of C arers.
The socio-economic characteristics of clients and carers investigated indicated that most were unemployed, with no regular source of income.Most of the clients fell within the productive age, where they are expected to be earning their own living and having families.
Most were male and unmarried and had to be supported and maintained they their families.
The views of carers varied over the role of the client.Some acknowledged that the client was ill and afforded him the sick person's status and exempted him from responsibihty of finding a job or even carrying out normal social duties in the home.Others felt that, because of the economic pressures that the family was facing, the chent, as long as he was out of hospital, would not be excused from taking up paid jobs to provide the family with income.Families who felt this was resented the cHents' idle behaviour, to the point of reftising them access to household facilities, including shelter.The same group of carers felt strongly that clients need rehabilitation to be able to be independent and that periodic admissions to hospital to relieve them of the burden of caring for the clients was essential.
Rehabilitation, as part of tertiary care, has been described as an expensive project, as it calls for provision of resources to cater for the varying needs of clients.In Botswana, rehabilitation services have m ostly been funded by non-governmental organizations and donor agencies from foreign aid.They have concentrated on the physical and m entally handicapped specifically.No project exists on record for the mentally ill sp ecifically for reh ab ilitatio n o f those discharged into the community.
The Occupational Health Unit in the only Mental Hospital is very small.It provides lim ited services for ju st a few, so that preparation for discharge is basically nil for most, especially the chronic patients.
The question of social welfare or maintenance of clients in the community is a difficult one.
Unemployed families have to rely on one member, even if it is an extended family member who is working for their support.Mental patients are not automatically eligible for social welfare, unless it can be proved that "The client if without assets (resources such as catde, other Uvestock, land, cash) cannot plough due to ill health or handicaps, close fam ily m em bers can n o t/w ill not help."(National Policy on Destitutes, 1980).
Although the poUcy is under review because of changes in the family structure and national economic trends, the situation will take a long time to change for the mentally ill because of the stigma associated with the ilhiess, and views held by some that the mentally ill in the community are fit to hold jobs and should make efforts to find jobs.Lack of transport has been mentioned as a problem throughout the report.
The needs to support carers has emerged as a discretionary activity by the nurse.It is concluded here that it should be seen as part of the main role of the nurse, in which skills, such as interpersonal procedures as described in the study, can be used.The family requires all services offered to the clients to promote their mental health and prevent mental illness by alleviating emotional and physical burdens from caring for the client.
Lack of rehabilitation services has been noted in the study to make the nurse helpless in providing service to both carers and clients.
The need for relief of this burden was the main thing expressed by carers.
The provision of the services mentioned above could lead to definition of what could be said to be professional community psychiatric mental health nursing.W hat has been observed in the study and literature reviewed is that community psychiatric mental health nursing is determ in^ by what has to be done for the mentally ill, based on resources available and as dictated by others with whom the nurses are working.
There is a need to develop some structure for both individual and community care of the mentally ill, with both short and long term objectives as a means of directing nursing activities in the conmiunity.Such structure and objectives could be used as ways of directing other community resources involved in the care of the mentally ill and their families, under the supervision o f the community mental health nurse.The strucmre might avoid haphazard functions which might be difficult to evaluate and control.
Information for carers in the direction of influencing self care appears to be inadequate.The involvement of low cost resources, such as volunteers and village health committees, may alleviate the manpower shortage in informing and educating the carers and other community members on the care of the mentally ill.
Provision of accommodation for the chronically ill without shelter could be considered as a matter of urgent need, to avoid patients becoming involved in serious crimes because of lack of proper monitoring of their medication.
Support groups in the community for famihes w ith schizophrenic clients living in the community are an essential resource in dealing with the emotional burden of caring for the mentally ill.Community mental health nurse could act as key persons in influencing community members to establish such support groups.
Constant evaluation of the programme by authorities, clients and carers would give the real picture of the success of failure of a community programme for the mentally ill, unlike evaluation of prescribed objectives.
The role of the community mental health nurse is n o t s ta tic , but c h a n g es c o n stan tly , depending on the factors identified above, including the characteristics of carers and clients, who are the consumer of care.
are the role activities of the community mental health nurse in the psychiatric unit, mobile clinics and during home visits?-How docs hc/she meet the program objectives to carry out health promotion and preventive services?-What therapeutic activities are carried out by the community mental health nurses and to whom do they refer clients when in doubt?-What are the problems faced by the c a r e r s o f c lie n ts d ia g n o se d as schizophrcnic?-What do carers want as help from the nurses?M E T H O D □ Sample: The nine community mental health nurses who graduated from a local training program with a similar educational background.
Twenty five carers participated in the study, three each fi-om seven of the areas in which the community psychiatric nurses are based and two each fi-om the other two areas.The other two carers from these areas dropped out of the study on the date of zppointment.One of the carers had to leave the village for some other important matters elsewhere while tiie second was not available at her home for the interview.
4. Basic nursing skills such as hygienic/nutrition care were ranked lowest.Nurses reported that such duties were left to families.N EED S AND P R O B L E M S O F c) An unmarried unemployed mother of four survives on money from selling firewood.Client is in early 20s with one daughter.'7 've got a lot o f problems.I am unem ployed, I've no one to look fo r help.She will not listen to me talking to her.She moves around with men andyet does not want to use fam ily planning methods.She does not even help me fetch fire wood to earn our living, she just roams around the village".Other children are at school.They live in a two-roomed flat."Violence and alcohol abuse is the main problem with the two o f them.They can't even get jobs to help me feed them.When they have rruiney from cas ual jobs, which they often get, they spend it all on alcohol and come home to demand fo o d I ju st can't cope with them ".a) "I really do not know what might be of help.I've been to traditional healers for help and the hospitals do not seem to be helpful at all" b) The elderly woman living with two clients, her daughter and her daughter's son, who are both schizophrenic, "I am an active church member.I 've even joined the women's group.When my so n 's illness started, I reported to the priest and the w om en's group.None o f them has set fo o t in my home to at least pray fo r me and my soru I 've decided to leave the church"."Traditional healers have begun charg ing high fees fo r their services.I 've run out o f money.I cannot afford it but maybe my daughter would get better".The fmdings have indicated the role of the Community Mental Health Nurse is indeed influenced by the setting where work takes place, his/her own perception of what her role is, the characteristics of those who receive care.