M.P.H., Faculty of Health Sciences, University of the Witwatersrand, 2011

This study presents a detailed account of Bridging Therapy - an innovative intervention aimed at providing relatively comprehensive psychiatric nursing care for mentally ill patients. Starting at hospitalisation, Bridging Therapy continues as planned nursing care based on detailed assessment of the patient's short- and longer-term needs both before and after discharge to the community, delivered where possible by the same nurse, or by members of the same nursing team. Bridging Therapy thus presents a remedial model for current fragmented patterns of nursing care, based on an eclectic approach to psychotherapy and nursing process known as the "flexible integrative approach" (FIA).The study recognises problems caused by lack of patient outcome measures in psychiatric nursing; and approaches this by developing an appropriate assessment instrument, the Behaviour Adjustment Inventory (BAI), which is initially tested in concurrent use with a well-validated psychometric instrument (the GHQ); with a second well-validated instrument (the EPI) acting as an initial screening device. The BAI assesses patients' initial status on admission and subsequent responses to Bridging Therapy on a five-point scale, used in conjunction with detailed clinical criteria of behaviour and attitude change. Clinical evaluation of patients in the contrasted contexts of Sheffield and Cairo is described. In each context, experimental (Bridging Therapy) and control (non-Bridging Therapy) groups are studied (Sheffield total N = 22: Cairo total N = 18). Assessment of initial condition was carried out on admission to hospital; recovery status on discharge, and at the close of therapeutic follow-up in the community. Results indicate similar levels of recovery for Sheffield and Cairo groups, with a more pronounced tendency to recovery in the experimental (Bridging Therapy) groups; however, this difference does not reach statistical significance. Psychometric findings are augmented by qualitative descriptions of the implementation process. Two detailed nursing studies from each context are presented. The investigation highlights the complexity of the research problem, including important transcultural considerations; identifies multifactorial issues governing patient care; and supports further research into Bridging Therapy as a potential remedy for current gaps in psychiatric nursing care, both in Britain and Egypt. Relevant materials concerning historical/structural aspects of mental health care and varieties of psychotherapy (Chapters 1 through 3) are included because of their contextual importance both to British and Egyptian workers.

Magister Curationis - MCur / The current debate on knowledge, attitudes and perceptions of medical staff and the broader community towards mentally ill patients across the world is also quite extensive in South Africa. The literature on the subject matter demonstrates poor knowledge of mental illness in the general population and also indicates that people often have stigmatising attitudes towards mental illness. However, while most studies have explored the attitudes, perceptions and behaviour towards mentally ill patients with respect to various staff categories such as doctors, nurses, pharmacists, psychologist and the community globally and particularly in Sub-Saharan Africa, few studies have extended the analysis to include general assistants. Moreover, little research has been carried out on the knowledge, attitudes and perceptions towards mental illness and mentally ill patients of non-medical staff such as general assistants, who on a daily basis spend time with mentally health care users, ensuring hygiene in psychiatric hospitals in South Africa. This study intended to fill the gap by using a quantitative, descriptive approach encompassing a cross-sectional survey design to identify the level of basic mental health knowledge and determine attitudes and perceptions of general assistants towards mental illness and mentally ill patients in four government funded psychiatric hospitals in Cape Town, South Africa. A random sample of 124 was selected from the general assistants of the four psychiatric hospitals in Cape Town. The results established that the majority of General Assistants (75.6%) in all four psychiatric hospitals demonstrated fair basic mental health knowledge pertaining to mental illness and positive attitudes and perceptions towards mentally ill patients. Although the attitudes and perceptions are mostly positive, item analysis revealed that there are disparities in the results. One third of the general assistants find it stressful to work with mentally ill people. Others displayed frustration (30,1% ), mistrust (52%) and fear(12%). In addition, 82.9% of the general assistants like working with mentally ill people and the majority of the general assistants are comfortable working with mentally ill patients. The recommendation is that basic mental health awareness programmes or in-service training should be implemented for general assistants especially newly appointed general assistants to improve the knowledge and understanding, attitudes and perceptions of general assistants and to reduce fear and negative perceptions and attitudes in order to enhance positive patient experiences.

In the United States, cigarette smoking is the main contributor to preventable death in all populations; and, among the mentally ill, the prevalence of smoking is a clinical practice concern. Nearly half of all smokers also have a diagnosis of mental illness compared with 23% of the general population. In an effort to reduce the problem of tobacco use within mentally ill populations, this project sought to create an educational module on smoking cessation for staff in a mental health clinic. The theory of planned behavior was used to guide the project that focused on implementation of a behavior change approach to counter smoking dependence. With evidence obtained from a comprehensive literature search of medical databases and textbooks, the education module was developed for teaching staff in a 30-bed outpatient mental health facility. Staff were taught to administer the education module on smoking cessation and to evaluate the plan. Evaluation of the project effectiveness on the knowledge of clinical staff was determined through the use of questions directed toward understanding professionals' perceptions of the module development and implementation, and the evidence-based educational materials developed for the program. Post tests administered after the staff education showed an increase in knowledge. The full education program was provided to the unit and will be used for staff training and for working with patients in the future. Positive social change is expected to occur because of the increased knowledge among clinical staff who care for mentally ill individuals who smoke. The result should be a safer, healthier setting for both smoking and nonsmoking patients in mental health clinics.

The purpose of this qualitative, explorative, descriptive and contextual study was to explore and describe nurses’ experiences of hostile behaviour from mentally ill patients in the psychiatric ward of a general hospital and to propose recommendations to the hospital management to support nurses who experienced hostile behaviour from mentally ill patients. Purposive sampling was used to identify the twelve nurses who participated in this study. Data were collected through in-depth face-to-face interviews, drawings and field notes. The data were analysed using Tesch’s descriptive method of open coding and the findings revealed that nurses experienced verbal abuse, physical abuse and sexual harassment from mentally ill patients, and had varied negative and positive responses to these forms of hostile behaviour. Main challenges were identified and recommendations were made to the hospital management to support nurses who experience hostile behaviour from mentally ill patients. / Health Studies / MA (Public Health)

The purpose of this qualitative, explorative, descriptive and contextual study was to explore and describe nurses’ experiences of hostile behaviour from mentally ill patients in the psychiatric ward of a general hospital and to propose recommendations to the hospital management to support nurses who experienced hostile behaviour from mentally ill patients. Purposive sampling was used to identify the twelve nurses who participated in this study. Data were collected through in-depth face-to-face interviews, drawings and field notes. The data were analysed using Tesch’s descriptive method of open coding and the findings revealed that nurses experienced verbal abuse, physical abuse and sexual harassment from mentally ill patients, and had varied negative and positive responses to these forms of hostile behaviour. Main challenges were identified and recommendations were made to the hospital management to support nurses who experience hostile behaviour from mentally ill patients. / Health Studies / M. A. (Public Health)

<p>The health care formulation of the principle of autonomy can be expressed as follows; ‘you shall not treat a patient without the informed consent of the patient, or his or her lawfulsurrogate, except in narrowly defined emergencies’. The principle of beneficence refers to a moral obligation to act for the benefit of others. In heath care, the good or benefit in question is the restoration of the health of the patient. In fulfilling this obligation of beneficence, the physician sometimes intentionally overrides the patient’s preferences or actions for the purpose of benefiting the patient. This is called paternalism. It therefore amounts to a violation of the principle of autonomy and hence there arises a tension or conflict between autonomy and beneficence.</p><p>The principle of autonomy claims to be pre-eminent to the principle of beneficence and vice versa. Both have their arguments as well as their limitations. However, there is the need for at least weak paternalism for the mentally ill patients because of their diminished autonomy. But in the case of the temporarily mentally ill patient whose autonomy is both restored and diminished following the periodic and intermittent occurrence of his or her mental illness, there is a need to go deeper to find justification for paternalistic intervention.</p><p>Both act and rule utilitarianism will find justification for paternalism in this case because the consequence of the action will be greater good for both the patient and the society. Kantianism will give it support from the point of view that the intention is to restore the autonomy of the patient by not using him or her as a means but as and end in himself or herself. Beauchamp and Childress will equally throw their weight behind the justification since prima facie obligations could be overridden in a conflict situation and since restricting a short term autonomy to protect and advance long term autonomy will appeal to common morality.</p>

The health care formulation of the principle of autonomy can be expressed as follows; ‘you shall not treat a patient without the informed consent of the patient, or his or her lawfulsurrogate, except in narrowly defined emergencies’. The principle of beneficence refers to a moral obligation to act for the benefit of others. In heath care, the good or benefit in question is the restoration of the health of the patient. In fulfilling this obligation of beneficence, the physician sometimes intentionally overrides the patient’s preferences or actions for the purpose of benefiting the patient. This is called paternalism. It therefore amounts to a violation of the principle of autonomy and hence there arises a tension or conflict between autonomy and beneficence. The principle of autonomy claims to be pre-eminent to the principle of beneficence and vice versa. Both have their arguments as well as their limitations. However, there is the need for at least weak paternalism for the mentally ill patients because of their diminished autonomy. But in the case of the temporarily mentally ill patient whose autonomy is both restored and diminished following the periodic and intermittent occurrence of his or her mental illness, there is a need to go deeper to find justification for paternalistic intervention. Both act and rule utilitarianism will find justification for paternalism in this case because the consequence of the action will be greater good for both the patient and the society. Kantianism will give it support from the point of view that the intention is to restore the autonomy of the patient by not using him or her as a means but as and end in himself or herself. Beauchamp and Childress will equally throw their weight behind the justification since prima facie obligations could be overridden in a conflict situation and since restricting a short term autonomy to protect and advance long term autonomy will appeal to common morality.

In South Africa, mental health care is being integrated into primary health care services. The integration of services was aimed at increasing the accessibility and availability of all health care services at primary health care level. The integration was well intentioned, and it was hoped that mentally ill clients would benefit from having a service near their homes. However, the process of integration is fraught with challenges, for instance, staff shortages, which lead to ineffective nursing management of mentally ill clients at the primary health care clinics. As a result, one professional nurse is often allocated to manage the clinic services on a daily basis with the assistance of an enrolled nurse or auxiliary nurse. The professional nurses therefore experience high levels of stress due to gross staff shortages and lack of time to conduct proper nursing assessments. This led to the research question: “What are the experiences of professional nurses with regards to the nursing management of mentally ill clients in rural primary health care clinics in the O.R. Tambo District in the Eastern Cape?’’ The proposed objectives of the study were to explore and describe the experiences of professional nurses working in rural primary health care clinics with regard to the nursing management of mentally ill clients. The researcher thereafter made recommendations to the district managers regarding effective nursing management of mentally ill clients in rural primary health care clinics. A qualitative, exploratory, descriptive and contextual design was used. The research population comprised of professional nurses working in rural primary health care clinics in the O.R. Tambo District in the Eastern Cape. Purposive sampling was used to identify participants and the sample number was determined by data saturation. Unstructured interviews and observation notes were used to collect data. The eight steps of data analysis suggested by Tesch were utilized to analyze the data. The researcher conducted an in-depth literature review in order to identify research gaps pertaining to the study. To ensure that a high level of validity and reliability was exercised throughout the study, the researcher conformed to Lincoln and Guba’s model of trustworthiness. The study was conducted in an ethical manner and ethical principles were adhered to. Findings: Three themes with subthemes emerged. The study showed that professional nurses experienced challenges related to the nursing management of mentally ill clients. These challenges included shortage of staff, a heavy workload, and lack of resources, lack of in-service training and workshops related to mental health issues coupled with lack of support from the supervisors. Due to the challenges, the mentally ill clients were not getting quality nursing care leading to complications and relapse. Conclusion: It emerged from the study that matters pertaining to mental illness and mental discomfort were still a serious problem in rural areas. The problems were related to the challenges which prevented professional nurses from providing quality nursing care to mentally ill clients with subsequent complications and relapse. Recommendations: Recommendations were made as an effort to ensure that the nursing management of mentally ill clients in rural primary health care clinics is improved. These recommendations were categorized as related to nursing practice, nursing education and nursing research.