Special Hearings — Mental Health Workshop — 1997-11-20

MS MOHAPI: Thank you, I'm Jeanette Mohapi and I come from Chris Hani Baragwanath Nursing College and I intend to share with you our experiences as nurse practitioners in psychiatric institutions and during clinical accompaniment of our students.  I may say we are very lucky people, you may call us participant observers because not everybody is able to witness continuously over 24 hours, the experiences of psychiatric patients and their miseries in these institutions.
 Doctor Zanele has already highlighted some of their problems and needs but as psychiatric nurses, we all feel that there is a sense of urgency that situation and nursing care should be upgraded because the standard of nursing care has really gone down. 
 We have a role to play - we have to as psychiatric nurse, to help in prevention of mental illness, promoting illness, helping people to get cured, help them to understand their experience of their personal misery.  However, we are unable - we do try, but we are unable to carry out this function.  
 One of our roles which we are supposed to really be implementing is to create a therapeutic milieu.  Now, this means that we must scientifically manipulate and plan the environment in such a way that the patient quickly gets well and off he goes but we are unable to do so because of staff shortage.  
 So, more than focusing on the nurse/patient relationship which is supposed to be interpersonal, we are more inclined to be rendering custodial care - that is, we quickly rush to the patients to the bathroom but in fact we do not take them to the bathroom, we use a hose pipe to shower them down so that we are quick and we rush them through and use that one towel to wipe them, so that we are through quickly because of the facilities.
 Now, one doesn't want to blame apartheid  but we are forced to talk about apartheid all the time.  The thing is, the National Party by placing a rules regulation in their books and doing things on the racial lines and so on, you'll find that our psychiatric buildings and ablution blocks are not the same as those of Whites.  If you go to Sterkfontein for example, one would find that what used to be a White section - now that you are mixing but used to be a White section, had tiles, smart curtains and so on and the other Black section which was far at the end, the floor were bare and so on.
 Things are trying to be improved however, I heard here that February 1976 inspection was done.  There is little improvement or none in some of the institutions but there is evidence of the differences, you feel the difference when you walk in what used to be a White psychiatric institution.   We are supposed to be providing self-care to patients and teaching them that, there is no time to do that as we are in too much of a hurry  Now the Government also - I don't know whether the Government did homework or not, they jumped into rationalisation of staff and this took away all the skilled psychiatric nurses we ever hoped to help the situation.
 So, we are back to square one.  So, instead of us as psychiatric nurses focusing on patients' needs, we are busy in little groups talking about our own concerns and about our own future and how tired we are, how burnt out we are, how useless the situation is.  We are killing even the spirit of those nurses who were trying to make a difference in the patients.
 Another thing is that we're supposed to be providing continuity of care, that is also impossible as we do not have enough time - we do try, but I must confess we do not have enough time to prepare patients and their relatives for discharge.  They're here today, gone tomorrow, back again.  
 And the saddest part is that this revolving syndrome is that when relatives bring back the patient, they say to us: "Sister, here's your person", they call the patients - not their relative or father or mother, they say: "Here is your person, take back your person as we cannot cope with person at home - he eats a lot, he is troublesome and so on".
 Now some of the patients in the long-term institutions prefer hospitalisation, they are well - they lack skills because we haven't empowered them to be retained in the community to survive, therefore they prefer to be in the institutions and the Government is facing a challenge of doing something about these people.  They actually tell you that: "Sister, when you discharge me I'm going to misbehave so that I come back to the institutions, that three meals a day and there's an area where I can sleep.
 Now, the other problem is that hospitals like Doctor Zanele said: "The institutions are overcrowded, overcrowded not because of new admissions all the time, overcrowded with people who have been in these institutions for more that 20 years and I again blame apartheid.  
 In 1997 I went to do psychiatric nursing in Bupule Hospital, when I got there it was about the time when the homelands were the in thing with independence, homelands and so on, now Bupule Hospital used to be mainly a very, very, large psychiatric institution.  Now at that time the patients had to be transferred to all over the show so that we make room for general medical care of patients, so three quarter of the hospital patients were removed to all over.  
 Now, if the Government can look into the issue of patients who are in institutions because for some reasons, they don't have home addresses, they are considered as homeless because nobody can trace where they come from because they were just removed from a familiar environment to far away places.  
 And then, again we are supposed to be advocating on behalf of clients and their families - I must confess we are not doing that, we are there - some of us, to impress the psychiatrist.  My experience of 31 years dealing with the doctors, is that there is this power struggle of who is more knowledgeable than the other one.  We as nurses, there is this power struggle that we became nurses because we had brain deficits or something - we are feeble minded or so.
 So, you dare not challenge the doctor and that is why I said to the nurses: "Empower yourselves with knowledge so that you have your facts straight and present yourself assertively to the doctor.  Now, there's this self-fulfilling thing about doctors and all of us to diagnose - to make a good diagnosis, my experience is that 99% of Black patients are schizophrenics. 
 It's so easy to say schizophrenia to all of them, you check all those files in long-term institutions - I'm telling you, when the doctors come and do their periodicals, sometimes they don't even look at the patient, they just add more treatment and so on.  Then, when we go for clinical accompaniment, we get this opportunity of students to present cases for us - we give them a patient, now that enables us for that individual nurse to have a one to one relationship with her patient, then they check the files and so on.  
 But some of the reasons for certification in 1940 or twenty years ago, are really wrong - I don't know Afrikaans but they are written in Afrikaans and the little interpretation I make is that this person was certified because he's a "Swart gevaar" or something, like maybe you clapped a White person or he stole something - I'm telling the truth because some of those reasons are not legitimate or were not.
 Now, the problem with this is, such a person was lost, picked up by the police, certified into an institution, family misses the person for 20 years.  Now, do you think the family is ready to take back an individual who cannot prove that he is not insane?  That is some of the problems, that when they are discharged they say: "You've been in a mental institution for so long, we don't want you".
 Now, we do not advocate as we should, we're busy pumping patients with psychiatric drugs which are ordered by the doctors because it's easier to handle the patient, the patient becomes less troublesome and then we can sit and read the Sowetan or whatever we want to do.  We seclude them, we restrain them for peace of mind - not of the patient, but of ours.   So these are just some of the summaries.
 And then we are supposed to be engaging in primary prevention of activities and try to dehumanise psychiatric nurses but I'm afraid we are still used as vehicles of continuously dehumanising a patient in the name of staff shortage, we do not have time to do that intervention.   I talked about the facilities of sleeping and over-population and the impossibility of implementing therapeutic milieu, that's when on daily sessions you ask your patient - you sit there.
 And the authorities, some of the authorities also - I don't what is the problem, they teach us this nurse/patient relationship but if a management walks in, you are sitting with a patient trying to find out what is wrong with the patient, it is considered as a waste of time - you should give them injections and carry on with other things.
 And another thing, we have this ethical dilemma - we often use our patients to cover staff shortages in performing manual work which should be done by hired people.  In the guys - that we are empowering in occupational skills or in vocational skills when really and truly, some of the things should be done by some of us.
 And I must say the nurses are trying but we are forced by circumstances to go for this quick fix approaches which do not help and which brings back the patient - our empathy skills are really burnt out.  So, I've summarised all that, that we are still allowing our patients to make decisions about their care.  We sort of think that the patient is mentally ill, her intellectual capacities are so down that she decide anything - we are inclined to push things down the patient.  We don't even have time for the relatives, we are very impatient.
 So, we were hoping that because of the TRC thing - of making recommendations, things can be pushed quicker for us to implement justice when it comes to patient care.  So, I don't know whether to go on under the recommendations or whether we will discuss them?