“Thrown in the Deep End” Experiences of Psychiatric Nurses Caring for Mental Health Care Users in the Selected Hospitals of Limpopo Province, South Africa

Abstract

Background: Management of Mental Health Care Users is a critical component of the overall health care system, yet it is not given the serious attention it deserves due to stigma and discrimination against those living with mental health challenges. These results in mental health care users being readmitted to the hospital frequently, despite the poor resources and overburdened health care system. Aim: The aim of this study was to explore and describe the experiences of Psychiatric Nurses regarding the care of Mental Health Care Users in the selected hospitals in Limpopo Province, South Africa. Methods: A qualitative study was followed, where explorative, descriptive, and contextual designs were used. The researcher purposefully selected thirty-four Psychiatric Nurses who have been working in mental health units. Data was collected through unstructured interviews. Thematic analysis was utilized to analyze the data. Results: The study revealed significant challenges, such as poor mental health structures or no mental health unit at all, and this forces Psychiatric Nurses to mix critically ill medical patients with psychotic patients. Furthermore, there is a shortage of staff and treatment to manage users. Conclusions: In conclusion, the study showed that psychiatric nurses face serious emotional and resource-related challenges in caring for mental health care users. This highlights the urgent need for support from institutions, ongoing training, and better working conditions to improve the quality of mental health care. The success of the care, treatment, and rehabilitation of mental health care users depends on the support of MHCUs by family and management.

1. Introduction

Mental health care is an integral part of the overall health care system but remains an area that is overlooked and often neglected globally. The care of mental health users diagnosed with mental health conditions is a difficult task, as they are fully dependent on Psychiatric Nurses for their recovery. Mental health conditions have been categorized into two, and these two categories are depression and anxiety disorders, where depression conditions were extremely high, with an estimated 322 million people diagnosed, and 264 million were diagnosed with anxiety disorders, which account for 4.4% globally [1] and this prevalence was high in females as compared to their male counterparts. Furthermore, more than 293 million individuals out of 2156 million individuals were found to have at least one mental health disorder, while 31 million individuals were suffering from substance use disorders in 2019 [2].

According to the World Health Organization (WHO, 2019), the prevalence of mental health disorders is increasing in populations, especially in low-income countries [1]. In the decade leading up to 2017, there has been a notable rise in the number of people suffering from mental conditions and substance use disorders by 13% [1]. Mental health has been noted to be increasing globally [3], where they need to be admitted to hospitals and care must be provided by Psychiatric Nurses in mental health units [4]. Since the last decade, there has been a record of more than 182 million people suffering from mental illness globally [5], who required delicate care by Psychiatric Nurses. A Mental Health Care User is a person receiving care, treatment, and rehabilitation services or using a health service at a health establishment aimed at enhancing their mental health status [6]. While a Psychiatric Nurse in this instance is a registered nurse, who has been trained to provide prescribed mental health care, treatment, and rehabilitation services; despite this, most countries have established mental health units to cater to those who need Care, Treatment, and Rehabilitation (CTR) [6].

Mental Health Units play a role in the accommodation of MHCUs who are psychotic and require CTR either in the Provincial or District institutions [4,7]. In South Africa, mental health care faces several challenges, including a high rate of readmission of MHCUs in poorly resourced mental health units with a shortage of staff [8], seclusion rooms, and drugs to treat psychotic users [9,10]. Several studies have been conducted in the field of mental health. Still, they mainly focused on the CTR of MHCUs [11,12] and neglected the views and experiences of the Psychiatric Nurses caring for the patients, especially in Limpopo province, where there is no availability of mental health structures to accommodate MHCUs, which leads to the Psychiatric Nurses mixing the critical medically ill patients and psychotic patients. The studies conducted focused more on the shortage of staff, lack of running water, and shortage of drugs to manage the MHCUs [13,14]. This practice of mixing MHCUs and critically ill patients introduces ethical, safety, and unique clinical practices in the CTR of users. Furthermore, by focusing on the experiences and challenges faced by Psychiatric Nurses under these conditions, this research study contributes a different challenge, which is at the core of proper patient management, and previous studies have underexamined certain dimensions of the discourse on mental health care delivery in South Africa. It can be underscored that Psychiatric Nurses are essential stakeholders [15] in the CTR of MHCUs whose views can influence policy reforms in the mental health discourse. The experiences of Psychiatric Nurses are crucial in the management of mental health care users, as they are directly involved in the care, treatment, and rehabilitation of mental health care users [16]. They are also regarded as the primary health care providers for the duration of the user’s stay in the mental health units [17], and their perspective might inform the policy [18] on the care of users and strengthen the community mental health, where the users are discharged to for continuity of care after being discharged from the mental health unit [18].

In other words, these health professionals provide empirical insights to enhance the management of MHCUs when patients are admitted to the mental health unit [4]. Based on this, it can be contended that there is a paucity of research in the management of MHCUs, which creates frequent re-admissions, known as a revolving door in mental health units [19]. Based on this, the study explored the experiences of Psychiatric Nurses in caring for the MHCUs in mental health units in Limpopo Province.

This study came at a time when mental health care was placed under the spotlight after 144 MHCUs died [20,21] in the care of unregistered mental health facilities around Gauteng Province, while other MHCUs were maltreated. Good management of MHCUs can result in a reduced burden on the system [22,23], which is under-resourced [9]. Consequently, the re-admission of users in mental health units is expected to decline, as users will be better cared for by their family members in their communities [24].

This study benefits the public health fraternity on many fronts; firstly, it highlights the importance of ethical obligations for caring for the MHCUs by Psychiatric Nurses [25]. Secondly, the study highlights best practices that bridge the gap between Mental Health Units (MHCUs) in mental health establishments and community health programs, aiming to prevent a revolving door for MHCUs [19]. Thirdly, the study is poised to contribute to a paradigm shift in prioritizing mental health issues through policy and education [26]. By exploring the experiences of psychiatric nurses in caring for MHCUs, areas for improvement in health service delivery can be identified, and strategies can be developed to enhance mental health care in the region [27]. Lastly, it highlights the role of community members in supporting MHCUs [28] as a way of complementing the efforts provided by Psychiatric Nurses in mental health establishments. The aim of the study was to explore and describe the experiences of Mental Health Care Practitioners regarding the care of Mental Health Care Users in Limpopo Province, South Africa.

2. Materials and Methods

2.1. Study Design and Setting

The qualitative approach was employed, with exploratory, descriptive, and contextual designs applied in the study. The study was conducted in selected hospitals of Limpopo Province. The province has five districts, namely: Vhembe, Mopani, Sekhukhune, Capricorn, and Waterberg Districts [29]. The Province has four hundred and sixty four clinics and health centers that provide outpatient care to the MHCUs, forty hospitals and almost all the hospitals conduct the 72 h observations, care, treatment and rehabilitation (CTR), and three specialized mental health establishments (Psychiatric hospitals), which admit only mental health care users, and they are situated in Vhembe, Mopani, and Capricorn Districts [29]. The researchers purposefully selected thirteen hospitals in Limpopo Province. Out of the total hospitals selected, eleven hospitals were chosen based on their high number of MHCUs admissions per month, while the two specialized hospitals are regarded as the custodians of mental health services [13].

2.2. Participants and Recruitment

The participants of the study included Psychiatric Nurses working in the mental health unit to provide care, treatment, and rehabilitation to MHCUs in Limpopo Province. The Psychiatric Nurses were selected based on their experience in working with the MHCUs so that they can share their experience caring for MHCUs in their respective mental health units. A total of 34 psychiatric nurses were purposefully selected to participate in the study, using an unstructured interview guide. Purposive sampling was appropriate and relevant to the study, as the researcher needed to select information-rich cases or those cases that were informative about caring for MCHUs in the mental health units.

2.3. Ethical Considerations

Ethical approval was granted by the University of Venda Research Ethics Committee (UVREC; approval number SHS/18/PH/09/2205). The Department of Health and the relevant hospital authorities also granted permission. Working with hospital management enabled us to recruit qualified psychiatric nurses who chose to participate after providing informed consent. We planned data collection to minimize interference with patient care, and we adhered closely to all ethical principles throughout the study.

2.4. Data Collection

The researchers are all trained psychiatric nurses and currently work as academics, bringing extensive experience in qualitative data collection and analysis. The researchers, as psychiatric nurses with specialized training in the CTR of MHCUs, approached the study with real experience in mental health care settings. This background gave us insight into clinical practices in mental health care. We recognize that this insider perspective may have affected how we interacted with participants and how we interpreted the data. This influence was particularly notable in terms of assumptions about routine practices or shared professional standards. To mitigate this effect, the researchers employed open-ended questions, avoided leading prompts, and focused on the meanings expressed by participants, rather than adhering to professional expectations. Regular peer debriefings and reflective discussions took place throughout the analysis to critically evaluate how our professional identities might have influenced coding and theme development. This reflective approach helped ensure that the findings were based on participants’ experiences rather than the researchers’ preconceptions. The researchers collected data from November 2018 to April 2019 using an unstructured interview guide with psychiatric nurses in the selected hospitals in Limpopo Province. The data was collected between 2018 and 2019, but it remains relevant as the factors affecting mental health care have not changed significantly since then. The interviews took place in a hospital setting, where a private and quiet office was used to avoid disruptions. An unstructured interview guide with a central question “May you kindly share with me your experiences of caring for MHCUs in the hospital” was used to explore the experiences of Psychiatric Nurses in caring for MHCUs in hospitals in Limpopo, and researchers conducted in-depth individual face-to-face interviews, and trustworthiness was ensured throughout the study through the application of credibility, dependability, conformability, and transferability. The interview guide was pre-tested with two Psychiatric Nurses, and no issues or corrections emerged from the pre-test. The results of the pre-test were not included in the study, and the participants were not part of the main study. The interviews were conducted using English, as the Psychiatric Nurses were all professional nurses. The audio recorder was used to record interviews, with written consent from each participant obtained prior to the start of the interview. Permission to use a voice recorder was requested and granted by participants. Participants were informed that they could stop recording at any time by pressing the stop button on the audio recorder if they did not want certain information to be recorded. Field notes were taken by the researcher and served as a backup for data collected, nonverbal information was captured, and no confidential information was tendered, as participants had never switched off the tape recorder during data collection. Data saturation was reached at participant number 29; however, the researcher added five more participants, but no new information surfaced [30]. The interviews lasted for about 30 to 45 min. The researcher, a trained psychiatric nurse with extensive experience working in mental health establishments, including acute, chronic, and forensic units, kept a reflexive journal during data collection and remained aware of potential biases that may have arisen during the process. Trustworthiness was ensured in this study, and credibility was achieved by accurately identifying the population based on their knowledge of the phenomenon under study. Furthermore, credibility was achieved as the researcher remained in the field for an extended period during data collection, until saturation was reached, and member checking was conducted with participants to confirm that the captured data accurately represented their information. Dependability and confirmability were supported by maintaining an audit trail of decisions and maintaining a reflexive journal during data collection and analysis. Ethical protocols were rigorously followed: participants were informed of their rights and assured confidentiality.

2.5. Data Analysis

Data were analyzed thematically using ATLAS.ti 8, following the six-step framework for data analysis as outlined by Braun and Clarke [31]. The first process of analysis involved familiarization and a comprehensive review of all the data obtained by repeatedly reading the transcripts and field notes. The researcher then employed a combination of deductive and inductive coding, whereby deductive codes were developed from the central research question, while inductive codes emerged directly from the participants’ narratives. Furthermore, coding was conducted in ATLAS.ti to organize, label, and link text segments and memos across transcripts. The researcher reviewed all the generated codes, determined patterns within them, and began formulating themes. Two researchers coded the transcripts separately. They established an agreement by comparing and discussing their coding results. They also employed peer debriefing and various methods to enhance the rigor, credibility, and trustworthiness of the analysis. The themes were reviewed to ensure that they are effective and precise representations of the Psychiatric Nurses’ experiences in caring for the MHCUs in the hospital.

3. Results

3.1. Participants’ Demographics

Thirty-four (34) psychiatric nurses participated in the study. All participants were South African and identified as African. The sample consisted of 14 males and 20 females.

Table 1. Biographical data of Psychiatric Nurses (n = 34).

Variable	Frequency	Percent (%)
Age
26–30	8	23
31–35	5	16
36–40	7	21
41–45	8	23
46–50	4	12
51 and above	2	5
Total	34	100
Designation
Professional nurse	30	88
Operational manager	4	12
Total	34	100
Years of experience
1 to 5	4	12
6 to 10	10	29
11 to 15	6	18
16 to 20	4	12
21 to 25	5	16
26 to 30.	3	8
31 and above	2	5
Total	34	100
Highest level of education
Diploma	24	71
Degree	10	29
Total	34	100%

Summary of biographical information for participants.

presents the detailed biographical information of the participants.

The majority of participants (60%) were between the ages of 26 and 40 years. Most were professional nurses (88%), with only a small proportion serving as operational managers (12%). Regarding experience, nearly 60% had been practicing for 15 years or less. Educationally, the majority held diplomas in psychiatric nursing (71%), while the remaining 29% held degrees. Both degree and diploma holders are psychiatric nurses; the difference lies only in the training institution, which is either a college or a university. These demographics provide context for understanding the practical and structural challenges discussed in the themes that follow.

3.2. Thematic Analysis

Qualitative data from the thirty-four Psychiatric Nurses were analyzed using Braun and Clarke’s six-phase thematic analysis framework [31]. This inductive process allowed themes to emerge naturally from participants’ narratives about their experiences caring for Mental Health Care Users (MHCUs) in selected hospitals in Limpopo Province. The deductive process had a few preconceived codes, including working conditions, availability of resources, including staff, psychological experiences, and anticipated support from management. Recommendations to improve the situation.

The study findings reflected different experiences of Psychiatric Nurses caring for MHCUs in the selected hospitals in Limpopo Province. Two themes emerged: Structural-related challenges and Resource-related challenges, with five sub-themes that arose from the experiences of Psychiatric Nurses, including: no wards for MHCUs, poorly constructed structures, a lack of seclusion rooms, a shortage of treatment, and a shortage of staff. The thematic analysis yielded two main themes with five sub-themes, as summarized in

Table 2. Summary of key findings on the experiences of Psychiatric Nurses caring for MHCUs.

Theme	Sub-Theme
Structural-related challenges	No wards for MHCUs
	Poorly built mental health structures No seclusion room
Resource-related challenges	Shortage of treatment Shortage of staff

Themes and Sub-themes from the study findings.

below.

3.3. Structural-Related Challenges

Participants reported that infrastructural challenges significantly hindered the delivery of quality care to MHCUs. Common issues included the absence of dedicated mental health wards, deteriorating structural conditions, and the lack of seclusion rooms for managing aggressive patients. These issues not only compromised patient care but also threatened the safety of staff and other users. The sub-themes below provide detailed insights into each structural barrier.

3.3.1. No Wards for Mental Health Care Users

Participants emphasized that their facilities lacked dedicated wards for MHCUs. As a result, psychotic patients were often mixed with critically ill medical patients, posing risks to both groups. This blending of patient types disrupted therapeutic environments and compromised safety.

Participant number 05, Female, 32 years old. “We don’t have a proper mental health unit to admit the mental health users. We have been allocated a cubicle in the medical ward to admit the users, and when we have more admissions, we are forced to mix the critically ill patients with the psychotic users because we don’t have a separate ward to admit them.”

Participant number 09, Female, 41 years old. “We do not have a specific unit for the mental health care users, so we improvise, a room that is a ward or cubicle for medical patients, and we use it to admit MHCUs.”

Participant number 28, Male, 28 years old. “The burning challenge for me, which I regard as a serious challenge or the highest challenge of them all, is that we do not have a mental health unit. We used to have a mental health unit, but it was burned a few years back, and it was never rebuilt. They then asked for one cubicle room from a medical ward so that we can be with the patients there.”

As one participant emphasized, without a dedicated mental health unit, the risk to both users and staff escalates:

Participant number 19, Female, 36 years old. “We have been allocated one cubicle in the medical ward, and the cubicle has only 7 beds. Sometimes we admit more users, and we usually have an overflow of patients to the medical ward. Those who are admitted for 72-h observations, at times, these MHCUs are more violent as they are still psychotic. There is also a high risk of users fighting and injuring each other or injuring the staff members (Psychiatric Nurses). When coming to work in the morning, you are unsure whether you will return home safely; we have been thrown into the deep end, and nothing is being done to improve the situation.”

These narratives highlight how the absence of specialized mental health infrastructure forces frontline providers to improvise care to MHCUs, often under unsafe and ethically complex circumstances.

3.3.2. Poorly Built Mental Health Structures

Participants revealed that their mental health structures are poorly built, and this makes it easier for the MHCUs to abscond. Participants highlighted that the mental health units are not being maintained, they were dilapidated, and the ceiling was falling. Another security issue was the mental health unit, which lacked a burglar-proof door, making it easier for users to abscond from the hospital.

Participant number 02, Female, 46 years old. “We are running our services here in this old building, as you can see, our building is very old and dilapidated.”

Participant number 22, a 38-year-old female. “In this building, if you go around and check, you will see the ceiling falling and very low, and that is the place they use to abscond. They climb up and get inside the ceiling, and then they walk across the roof until they find an exit to jump off and run away from the hospital. Sometimes they use the burglar windows to escape; they slip through the windows, and off they go out of the hospital.”

The poor structural conditions not only allowed patients to abscond but also contributed to a pervasive sense of insecurity among staff. Lack of maintenance, outdated buildings, and faulty security features were cited as ongoing risks to both patients and Psychiatric Nurses.

3.3.3. No Seclusion Room

Findings of the study revealed that Psychiatric Nurses resort to using chemical restraints for violent and aggressive users, as they do not have a seclusion room to keep them. The lack of a seclusion room makes it difficult to conduct 72 h observations, as the patient will always be sedated until the observation period lapses.

Participant number 11, Female, 29 years old. “In the current situation, it is very difficult to conduct the 72-h observations as we are required by the Mental Health Care Act (MHCA) because our patients are heavily sedated, especially those who display violent and aggressive behavior, and there is no seclusion room in the hospital. We are just managing the situation in this cubicle.”

Participant number 01, Male, 31 years old. “We solely depend on chemical restraint, which is sedation, when the user is violent or aggressive. Sedation is our only resort because we don’t have a seclusion room.”

The reliance on chemical restraint due to the absence of a seclusion room raises ethical and clinical concerns. While sedation may offer immediate containment, it may hinder accurate psychiatric observation during the crucial 72 h assessment period mandated by the Mental Health Care Act.

3.4. Resource-Related Challenges

Study findings revealed that Psychiatric Nurses experience a shortage of resources, such as drugs used in the management of MHCUs, and they use substitution, which sometimes is ineffective. The participants also revealed that they are short-staffed, which makes it difficult for them to provide quality care to users, given the high nurse-patient ratio. In addition to infrastructure, participants identified resource shortages as critical impediments to delivering quality mental health services.

3.4.1. Shortage of Treatment

Participants described the challenge of the shortage of treatment to control and manage MHCUs while admitted to the hospital. This will compel the doctors to change or substitute the treatment with whatever is available, and some of the users do not respond to the treatment, which makes them relapse and are frequently readmitted to the mental health unit.

Participant number 15, Female, 33 years old. “We have frequent readmissions in the mental health unit because of the challenge we are experiencing, whereby the treatment is out of stock, and they will be given alternative drugs, which are ineffective for them.”

Participant number 21, Female, 26 years old. “We have a serious challenge of a shortage of treatment or drugs for mental health in the hospital; we just give them what is available, and it doesn’t work for all the users, especially those with Substance-Induced Psychosis (SIPD).”

Substituting unavailable medications with less effective alternatives was linked to frequent relapses and readmissions. This practice undermines continuity of care and frustrates both patients and providers, compounding the pressure on already overwhelmed units.

3.4.2. Shortage of Staff

The number of staff members allocated in the mental health units was said to be very low, as compared to the number of users being admitted. This was highlighted as a main factor that contributes to the Psychiatric Nurses failing to provide quality patient care to users. Furthermore, participants cited that the allocation of male nurses in the mental health unit is very important as they assist when the users fight or get violent, they depend on security, and they are afraid to come close to the users at times.

Participant number 26, Female, 53 years old. “We are having a serious challenge when it comes to the human resources in the mental health unit, or to be honest, in the whole hospital. We are a small team, and you can’t manage all these patients alone; we need to be many so that we can provide quality patient care to our mental health care users. We need more manpower here, but currently we are very short-staffed.”

Participant number 32, Male, 39 years old. “In this unit, basically, we are short-staffed; we don’t have enough qualified psychiatric nurses. Today, we are only two; I’m here writing the files, and the other Psychiatric Nurses are busy running a mental health clinic today. So, we need more manpower to assist in the management of MHCUs.”

4. Discussion

This study explored the experiences of psychiatric nurses caring for MHCUs in selected hospitals in Limpopo Province, South Africa. The findings highlight two overarching themes: structural challenges and resource-related challenges, both of which significantly affect the quality and safety of psychiatric care.

Participants reported that the absence of dedicated mental health wards compelled facilities to house MHCUs alongside medically ill patients, which heightened risks for both groups. This resonates with findings from Limpopo Province, where outdated infrastructure and overcrowding compromised patient safety and therapeutic care environments [13].

Poorly maintained buildings with dilapidated ceilings and unsecured windows were also reported, which facilitated patient abscondment—a concern mirrored in studies that emphasize infrastructure as a critical determinant of safety and rehabilitation in mental health settings [10].

The absence of seclusion rooms emerged as a major obstacle. Staff frequently resorted to chemical restraints, which compromised accurate psychiatric assessment during the mandated 72 h observation period. While some global discourse critiques seclusion as potentially inhumane, a scoping review of psychiatric emergency practices in Africa confirms that, when managed ethically, seclusion remains a necessary last-resort intervention to ensure safety in resource-constrained settings [32]. Locally, Sehularo et al. (2024) [33] also underscore the importance of safe seclusion spaces as part of coping strategies for managing violent or aggressive users.

Medication shortages were a recurring theme in this study, with participants citing frequent stockouts and reliance on alternative, sometimes ineffective, drugs. Similar findings have been documented across South Africa, where erratic medication supply chains undermine continuity of care, resulting in relapses and frequent readmissions [9].

Staffing shortages were equally critical. Nurses reported high patient-to-staff ratios, compounded by the scarcity of male nurses, who are often expected to assist in managing aggressive users. This echoes prior research describing South Africa’s psychiatric nursing workforce as being in a state of crisis, especially in rural public facilities [14]. Burnout, emotional strain, and fear were also highlighted, consistent with studies documenting stress among psychiatric health care workers under poor working conditions and limited resources [34].

4.1. Implications

The challenges identified in this study are not isolated to Limpopo Province but reflect a national and regional trend of underinvestment in mental health services. Infrastructural deficits, medication shortages, and chronic human resource gaps collectively undermine safe, effective psychiatric care. These findings align with calls for South Africa to prioritize mental health as a core aspect of overall health care planning and investment [9].

The study also emphasizes the emotional toll on psychiatric nurses, who navigate unsafe environments, medication scarcities, and staff shortages while striving to maintain patient dignity and safety. Constant substitution of MHCUs treatment may lead to poor compliance, resistance to prescribed drugs, which may increase relapse psychosis, and this might worsen long-term prognosis. Addressing these systemic gaps is essential not only for improving patient outcomes but also for protecting the well-being of frontline health care workers.

4.2. Limitations

The study was limited to facilities within one province, where most hospitals serve rural populations. Findings may not be generalizable to urban or better-resourced contexts. Moreover, only psychiatric nurses were included, excluding other mental health professionals such as psychiatrists, psychologists, and social workers whose perspectives could enrich future research.

4.3. Recommendations

Based on the findings, several recommendations emerged from the study. First, there is a need to take mental health seriously, like other chronic diseases, and provide support in terms of building the structure that enhances the therapeutic milieu of the MHCUs admitted to the hospital. Secondly, the allocation of staff must consider male nurses in the mental health units, as they serve as manpower to the violent and aggressive users. Lastly, treatment or drugs used in the management of MHCUs must always be available to avoid frequent readmission of users, as the alternative drugs sometimes are not effective.

5. Conclusions

In conclusion, this study provides valuable insights into the experiences of psychiatric nurses caring for patients with mental health issues in hospitals. It highlights ongoing challenges, including poor infrastructure, medication shortages, and insufficient staff. The findings emphasize the need for targeted efforts, policy support, and government involvement to improve mental health services. This study highlights systemic barriers in the care of MHCUs in South Africa, particularly infrastructure deficits, medication shortages, and inadequate staffing. These issues pose a threat to both patient and provider safety. Urgent action is required at both policy and institutional levels to strengthen infrastructure, secure medication supply chains, and expand and retain the psychiatric nursing workforce. Without such interventions, psychiatric units will remain sites of vulnerability rather than recovery.