Exploring primary mental healthcare nurses’ perceptions of the post-treatment needs of women admitted for psychiatric treatment

Primary mental healthcare nurses are an essential workforce that provide necessary inpatient psychiatric treatment. Continuity of care has become a significant aspect of the provision of mental health services. However, caring for South African healthcare users comes with challenges, including difficulties accompanying the provision of care for acutely ill patients with complex mental health problems. Therefore, this study explored the perceptions and experiences of primary mental healthcare nurses concerning the continuity of care required in post-inpatient psychiatric treatment for mental health users from low-income communities in the Western Cape. Through undertaking a study using a qualitative exploratory design and purposive sampling technique, and in which nine primary mental healthcare nurses from two psychiatric hospitals in the Western Cape were interviewed, the researchers were able to obtain a deeper understanding of the participants’ experiences. Four themes were identified during the reflexive thematic analysis namely: the roles and responsibilities of primary mental healthcare nurses, the lack of support within the current continuity-of-care system, barriers to continuity of care for women patients, and suggested improvements for quality of mental healthcare. It was evident that both women patients and primary mental healthcare nurses experienced various forms of marginalisation, discrimination, and gendered oppression. This intersectionality accentuates systemic issues within the current public healthcare system and highlights the stigmatisation of mental illness, especially among women. Overall, primary mental healthcare nurses have a plethora of roles and responsibilities within the primary healthcare sector, which hinder their ability to provide mental health services to women patients. Their reports highlight the needs of a specific patient population that first need to translate into changes that will assist in improving their roles as primary mental healthcare nurses. Their shared experiences of a lack of support from South Africa’s healthcare system were the focal points of this study.

those in need.The strain on the healthcare system has resulted in increasing pressure on the mental health facilities currently available within the South African public health sector (Maphumulo & Bhengu, 2019).
Currently, there are several challenges in implementing mental healthcare services in South African communities, the most prominent of which is the lack of human and financial resources to assist community members who require continuous mental healthcare services (Schneider et al., 2016), especially after they are discharged from hospitals.To alleviate the strain on government hospitals and clinics, many community-based non-profit organisations provide continuity-of-care services to community members with mental health disorders who have been discharged from hospitals (Mkhize & Kometsi, 2008).
Continuity of care refers to 'a continuous relationship between patient and doctor [/health practitioner], to ensure a type of "seamless service"' (Gulliford et al., 2006, p. 249).Primary mental healthcare nurses (PMHNs), who are located within government community clinics, typically assume responsibility for women discharged from local psychiatric institutions.To ensure continuity-of-care services, the role of PMHNs in the psychiatric environment is essential in providing patients with daily psychiatric care and ensuring that they adhere to their prescribed medications (Sobekwa & Arunachallam, 2015).
According to Naylor and Kurtzman (2010), PMHNs tend to work very long hours, have limited family time, and become frustrated with the persistent lack of resources and medication, resulting in most nurses feeling burnt out.In part, this is due to understaffing within these clinics.According to Silverio (2021), research and practices regarding women's mental health are often overlooked in the public health environment.Chou and Tseng (2020) concur and further suggest that more research needs to be conducted on the implications of the barriers to the continuity of care for patients within primary healthcare facilities.

Statement of the research problem
Nurses are the foundation of a country's healthcare system as they play a significant role in reducing mortality rates, encouraging healthier lifestyles of patients, and ensuring the achievement of the United Nations' health-related Sustainable Development Goals (Yakubu et al., 2022).Mental health promotion, mental disorder prevention, and provision of mental healthcare are fundamental services provided by primary healthcare facilities in South Africa (Onwubu et al., 2023).However, South Africa is experiencing a scarcity of trained healthcare professionals, as they often migrate from the public to the private sector, where they are generally better remunerated (Mokoena, 2017).Owing to the lack of specialised mental health specialists, task-shifting and task-sharing strategies have become necessary in the healthcare sector (Moodley et al., 2022).Sobekwa and Arunachallam (2015) found that there are not enough healthcare workers in South Africa to handle the large number of mental healthcare users as well as high admission rates.This often results in an unbearable workload for the healthcare workers.Pressured workloads would undoubtedly hinder the ability of healthcare professionals to deliver high-quality services, which can compromise patient treatment outcomes (Kigozi-Male et al., 2023).
Despite the shortcomings of PMHNs, little is known about the difficulties encountered by these nurses on a daily basis.By exploring the perceptions of the PMHNs, the researchers hoped to gain a deeper understanding of the systemic and hierarchical structures within local clinics and their impact on healthcare services.This study endeavoured to address this gap by undertaking an exploratory approach to understand the continuity of care for women discharged from Female Acute Units at two mental health hospitals in Western Cape, South Africa.

Aim of the study
This study aimed to explore the perceptions of PMHNs concerning the continuity of care required in post-inpatient psychiatric treatment for women admitted for psychiatric treatment in low-income communities in the Western Cape.

Method
This study employed an exploratory qualitative research design.Data were collected through semistructured interviews with nine PMHNs.These PMHNs were from various community clinics connected to two major psychiatric facilities in the Western Cape.Nine interviews were conducted telephonically and by means of online platforms (Microsoft Teams and Zoom).All interviews were facilitated by the authors.The interviews lasted approximately 20-30 minutes, as the interviews had to be scheduled around the participants' break times.An interview schedule was developed to guide the researchers.The interviewers were interested in understanding the PMHNs' roles, responsibilities, and the complexities of working within the mental healthcare system in local South African clinics, as very little information exists regarding the current structures that govern post-treatment available to patients discharged from Female Acute Units at government psychiatric hospitals in the Western Cape.The PMHNs were recruited using purposive and snowball sampling.The inclusion criterion was that participants had to be PMHNs working with patients discharged from Acute Female Units at two psychiatric hospitals in the region.The interviews were conducted in English.Codes and themes were generated independently using the ATLAS.tisoftware.
Ethics approval was obtained from the University of the Western Cape's Biomedical Science Research Ethics committee (BM22/3/4), the Western Cape Department of Health, and the relevant health facilities in which the PMHNs were sourced.All participants were provided with a Google Forms link to provide digital consent.Informed consent was obtained from each participant, and all participants agreed to be recorded during the interview.Interviews were transcribed verbatim.Pseudonyms were used to ensure anonymity and confidentiality.

Participants
The PMHNs (n = 9) in this study all identified as women, spoke regional languages, and were between the ages of 39 and 59.The PMHNs were quite experienced, with the number of years they had worked in the public sector (in the Cape Metropole) ranging from 9 to 26 years.

Data analysis
Braun and Clarke's (2019) reflexive thematic analysis was employed to analyse the collected data.The strength of Braun and Clarke's (2019) reflexive thematic analysis approach is that it is pragmatic, descriptive, and therefore, appropriate for this exploratory study.Reflexive thematic analysis entails critical exploration and analysis of how the researcher's personal experiences, values, prior knowledge, and social position (such as gender) influence and contribute to how they interpret the data (Braun & Clarke, 2019).The process of reflexivity was achieved with multiple researchers analysing and revising the codes and themes initially generated.After revising the article, the themes and transcripts were also revised to ensure that participants' experiences and the aim of the study remained aligned.Following the iterative process of coding and theme generation, four themes were identified.

Findings Theme 1: roles and responsibilities of PMHNs: the challenges of women as PMHNs in relation to their patients
In the primary healthcare system, PMHNs are responsible for a plethora of roles, including followup appointments, discussing well-being and medication with patients, ensuring patient compliance with medication, and providing referrals to social workers where this is required.However, PMHNs do not only serve and support women who have been discharged from inpatient facilities, but also provide mental health-related services to men and children in the local community.It can be challenging for women patients and the PMHNs, who are also women, to balance these roles.This is evident in the following quotes: A lot of women these days. . .you have to look after your kids, you are employed, you're a mom, you're a wife, and you have a mental illness -can you imagine the pressure on a woman like that? (P5).
That is not the end of the treatment.You know, and some of them actually don't want to go back [home], you know, because it was so terrible.So I think my role is just to listen to them, and in that, encourage you know, because sometimes there's major problems up there.They don't tell the doctors maybe in, Grote Schuur or in Valkenberg, but now they come to the community.And now I have to deal, you know, the workplace as the, as the family, you know, and my role is, also to educate not These examples highlight the intersectionality of roles that result in both groups of women (PMHNs and patients) being discriminated against, despite their different positions within the patient-service provider dynamic.Both women patients and women PMHNs are overburdened with the societal roles associated with being a woman, leading to further marginalisation and gendered oppression.
Theme 2: lack of support within the current continuity of the care system Based on this marginalisation and discrimination, there seems to be a lack of support for women patients and PMHNs within the South African healthcare system.Patients face many challenges that exacerbate their mental health disorders, such as poverty, gender-based and domestic violence, lack of family support, and managing various roles, which often lead to relapse.
Social circumstances are a big problem.A lot of patients come from really violent areas.They are exposed to a lot of psychosocial stressors due to the environment that they are in, so they relapse again due to the environment.(P7) I wanted to emphasise that we are concerned about our women's health and especially, as I said, if there is a partner that is quite violent, or domestically violent or she's depressed or even she's got suicidal thoughts, we are worried [. . ..]I think the pressure is on women because they have such responsibilities.(P8).
Not only do patients lack support within the environments in which they function, but PMHNs are also not adequately supported to provide mental health services to the public.The PMHNs have to contend with structures that are understaffed, inadequately resourced, and have inadequate infrastructure.According to them, they are expected to work optimally in stressful environments.These systemic issues, and unequal power relations, are best encapsulated in the following statement by one of the PMHNs: We don't have power at the moment, so we can constantly request support but yes, we don't see any changes.(P10) The feelings of powerlessness, lack of support, inadequate infrastructure, and conflicting roles compromise the mental health of women within the healthcare system.

Theme 3: barriers to continuity of care for women patients
Notwithstanding the lack of support from their partners in continuing their treatment, unemployment and financial hardship are discussed by PMHNs as some of the main inhibitors for women patients when accessing mental health services.It was clear from the interviews that a lack of financial stability profoundly affect the likelihood of women patients receiving psychological support.This is illustrated in statements such as the following: I would say finances [. ..] no money is available.And then also the distances that people have to travel to go and attend these resources.(P1) These obstacles seem to be experienced by both the women patients who want to feel supported and PMHNs who want to support them in their recovery.
In addition, women patients experience stigmatisation for mental health disorders, leading to a decrease in the number of patients who continue the psychological support made available to them.The main concern expressed by most PMHNs is that the community needs to be educated on mental health and its importance: The community needs to be educated because now everybody thinks she's a mad woman, you know [. ..] the community needs to be educated.(P4) The stigmatisation of mental health in these communities leads many women to seek help only once their mental health has deteriorated significantly.

Theme 4: suggested improvements for quality of mental healthcare
PMHNs are vital for providing women patients with quality continuity of care.Without appropriate resources, the quality of this care may be compromised.According to one of the PMHNs, At the clinics, we don't have any resources.It's only the mental health nurse.So, we don't have a doctor, we don't have OT, we don't have a social worker.(P2) Therefore, there needs to be an increase in staff and redistribution of PMHNs within local community clinics for PMHNs to provide more effective and efficient services to women patients.
Staff retention within local community clinics has also been described as an issue affecting the quality of care.This was noted in the following statement: The clinics are always understaffed . . .there is no continuity, people change regularly, and patients become frustrated if they need to see a different person every time.(P5) Here, it is evident that PMHNs can see the negative effects of healthcare-related systemic issues in respect of the mental healthcare provided to the patients.These systemic issues often lead to poor mental health outcomes and prevent the formation of a trustworthy relationship between the patient and healthcare provider.PMHNs expressed feelings of frustration and hopelessness with the lack of infrastructure within the healthcare system, as this has a long-term impact on both them and the populations they serve.This cyclic notion of feeling overlooked and undervalued, as both the service providers and the women patients, is accentuated by the following quote: We have been trying to change that for patients who have been coming here for months now[. ..] but unfortunately the system isn't going to change.We just have to deal with this structure.(P8) Therefore, even though the PMHNs desire to be more readily available and provide quality continuity-of-care services to women patients, they indicate that a lack of trust can cause long-term problems in respect of establishing rapport and care within a therapeutic relationship.

Discussion
Many women in South Africa, in addition to being the primary breadwinners, are bound by social constraints to dedicate time to labour at home, such as childcare and the majority of domestic chores (Parry & Segalo, 2017).Being a woman and needing to continue treatment, especially after being discharged from a psychiatric facility, presents a complex challenge.This finding is consistent with what is reflected in the global literature.As previous studies have indicated, the multiple roles inhabited by women in contemporary patriarchal societies, such as South Africa, impede their work-life balance (Jaga et al., 2018).However, there is a lack of South African literature that speaks to the impact of this inhabitation of multiple roles on the mental health recovery of women and the women who provide this care.In addition to the exacerbation of mental illness due to the multiple roles assumed by women, the findings indicate that patients involved in continuity-of-care services are subjected to a variety of other psychosocial stressors known to impact their recovery.These include, but are not limited to, financial instability (Lund et al., 2010) and intimate-partner violence (Gibbs et al., 2018).These are, of course, not limited to women inpatient care but are rife in the South African context (Francis & Webster, 2019;Gibbs et al., 2018).The PMHNs described these as significant barriers to treating women once they were discharged.
PMHNs also expressed dissatisfaction with the lack of systemic support (lack of resources such as finances, and medical and other mental health specialist support), which impedes their capacity to provide adequate support to the large communities that they serve.This experience is not surprising given South Africa's underfunding of mental healthcare resources.Docrat et al. (2019) stated that during the 2016/2017 financial year, only 4.6% of South Africa's national healthcare budget was allocated to inpatient and outpatient mental healthcare services.Moreover, there was significant shortage of mental healthcare professionals.This is consistent with the findings of a 2019 national survey, which reported that the Western Cape has 0.89 psychiatrists, and 1.22 psychologists, per 100,000 uninsured people (Docrat et al., 2019).Owing to this severe dearth of mental health professionals, Docrat et al. (2019) argue that nurses in primary healthcare are a 'key resource to mental health service delivery' (p.717).The Western Cape has the lowest outpatient mental healthcare budget of any South African province (only 9.5%) (Docrat et al., 2019).Therefore, it is obvious that there is a necessity for redistribution of funds and policy reform within the South African healthcare sector.
PMHNs indicate that one of the predominant barriers to accessing quality mental healthcare services is some women's lack of stable income.This finding is supported by a 2013 study, which found that South African women are far more likely than men to incur a loss of income owing to mental disorders (Lund et al., 2013).With this in mind, just as the continuity of care patients' experiences are shaped by their identity as women, they are simultaneously shaped by their socioeconomic status, leading to the perpetuation of poor mental health as the few resources that exist remain inaccessible.
In addition to financial constraints, stigmatisation was also listed as a core barrier to accessing continuity of care by women patients.This finding was anticipated, as studies have shown that the stigma attached to ill-mental health in South Africa remains pervasive (Egbe et al., 2014;Monnapula-Mazabane & Petersen, 2023).This stigma is often attributed to lack of understanding.Therefore, PMHNs recognise the need to include family members in their patients' aftercare.This could be in the form of interventions that educate families of patients, as well as broader communities, about the realities of mental health disorders and accompanying stigmatisation.
At their core, the suggestions provided by the PMHNs to improve the quality of continuity-ofcare interventions that they can provide to women seem to focus on staffing.This finding mirrors the human resource crisis outlined by De Kock and Pillay (2016), who found that in public, rural, and primary healthcare facilities in the Western Cape, there is one PMHN per 100,000 community members.Worryingly, the same study also cited that between 2007 and 2013, four South African provinces did not have any qualifying mental healthcare nurses (De Kock & Pillay, 2016).Underresourcing in general not only affects the services provided to women patients but also leads to burnout and fatigue, which affect PMHNs' overall well-being in turn (Tununu & Martin, 2020).

Limitations
Although this study focused on PMHNs who provide post-treatment for women, it was clear from the interviews that these PMHNs work with diverse patient samples, including adult males, paediatric patients, older adults, and persons from the LGBTQ+ community.Therefore, further research should be conducted on the impact of the current mental health services on these diverse groups.In the process of acquiring participants, the core difficulty was recruitment.As PMHNs were already highly overloaded and inundated with patients, many PMHNs opted out of the study.Future interventions and programmes would need to factor the understaffed and overloaded context within which these PMHNs operate as well as the complexities associated with the continuity of care as a result.Furthermore, the number of communities for which each PMHN is responsible to provide care and support to was not determined in this study.This information is essential for understanding the severity of their challenges and addressing them to provide more effective care in the future.

Conclusion
PMHNs are overburdened, overwhelmed, and experience multiple challenges in their endeavours to provide sustainable and effective patient care.The information they provided highlight the changes needed to be a more effective PMHN for their clients.Their shared experiences of a lack of support from South Africa's healthcare system were the focal points of this study.PMHNs are in a unique position to provide this information because of their roles as both PMHNs and women.This study identified an important area in dire need of future research.The first concerns the impact of inhabiting multiple roles on mental health and recovery of women in South Africa.What is the impact?How can this problem be mitigated?Policymakers and those who make decisions regarding mental healthcare budgets should ensure that they take these results into consideration.This will improve the quality of treatment for women with various mental health disorders in South Africa.
[only] the patient, but the whole family, um, about the diagnosis and what's happening and what is the process, yeah.(P2)