Nurses’ Experiences of Mental Healthcare Assessment and Documentation in Psychiatric Admission Units in Rural Limpopo Province, South Africa.

2.1 Research design

This study employed a qualitative, exploratory, descriptive, and contextual research design to explore nurses’ experiences of mental healthcare assessment and documentation during the admission of mental healthcare users (MHCUs). A qualitative approach was considered appropriate because it enabled an in-depth understanding of participants’ lived experiences, perceptions, and challenges within their natural clinical settings.¹⁰ The exploratory and descriptive nature of the study enabled the researchers to investigate an under-researched phenomenon and generate rich contextual insights into mental healthcare assessment and documentation practices in rural emergency settings.¹¹

2.2 Study setting

The study was conducted in the psychiatric admission units of two rural referral hospitals, namely Donald Fraser Hospital and Elim Hospital, located in the Vhembe District of Limpopo Province, South Africa. These hospitals provide both general and mental healthcare services and serve predominantly rural communities with limited access to specialised psychiatric resources. The selected facilities manage acute psychiatric admissions, including mental healthcare users (MHCUs) presenting with psychosis, aggressive behaviour, substance-induced mental disorders, and other psychiatric emergencies requiring assessment, stabilisation, and ongoing observation.

The hospitals were purposively selected because they function as referral centres for surrounding primary healthcare clinics and district hospitals and frequently manage high volumes of MHCUs under resource-constrained conditions. Psychiatric services in these settings are largely nurse-driven due to shortages of specialised mental health professionals, including psychiatrists and psychiatric nurses. These contextual realities made the selected hospitals appropriate settings for exploring nurses’ experiences of mental healthcare assessment and documentation during MHCU admissions.

2.3 Population and sampling

The study population comprised professional nurses working in the psychiatric units of the selected hospitals. A purposive sampling technique was used to recruit participants with direct experience in assessing and documenting MHCUs who could provide rich, relevant information about the phenomenon under study.¹¹ Inclusion criteria included registered professional nurses with at least two years of experience in psychiatric nursing and active involvement in MHCU admission processes. Nurses who were on leave or unwilling to participate were excluded from the study. Sampling continued until data saturation was reached with the fourteen participants, and confirmed with an additional two, at which point no new themes or insights emerged. All recruited participants voluntarily agreed to participate in the study.

2.4 Research team and reflexivity

Data were collected by the primary researcher, a female professional nurse with experience in mental health nursing and qualitative research. Although the researcher had prior exposure to psychiatric care settings, reflexive practices were applied throughout the study to minimise the potential influence of personal assumptions and professional experiences on data collection and analysis. Reflexive journaling, memo writing, and regular discussions with the supervisory team were used to facilitate bracketing and ensure that the findings remained grounded in participants’ lived experiences.¹²

The researcher was not employed by the participating hospitals and had no prior relationship with the participants, thereby reducing the likelihood of role-related influence during the interviews.

2.5 Data collection

Data were collected between May and July 2025 through semi-structured, one-on-one interviews conducted by the first author under the supervision of experienced qualitative researchers. Semi-structured interviews were selected to allow participants to describe their experiences freely while enabling the researcher to probe for clarity and depth.¹³ Interviews were conducted in English in private rooms within the hospitals and lasted approximately 35–45 minutes. They continued until data saturation at 14, with an additional 2 for confirmation, for a total of 16. No repeat interviews were conducted.

The central interview question was: “Kindly share with me your experience of conducting nursing assessment and documentation of mental healthcare users during admission.” Probing questions were used to explore challenges, teamwork, legal documentation, and strategies used during assessment and documentation. With participants’ permission, interviews were audio-recorded and supplemented with field notes to capture non-verbal cues and contextual observations.

A pilot interview was conducted with five nurses from another hospital in the district to assess the clarity and feasibility of the interview guide. Data from the pilot study were not included in the final analysis.

2.6 Data analysis

Data were analysed using Tesch’s eight-step open-coding method (Creswell, 2014). Interviews were transcribed verbatim and checked against audio recordings for accuracy. The researcher repeatedly read the transcripts to gain familiarity with the data before identifying meaningful statements and generating initial codes. Similar codes were grouped into categories, which were further organised into themes and sub-themes.

To enhance trustworthiness, an independent co-coder experienced in qualitative research analysed a subset of transcripts independently. Consensus discussions were held between the researcher and the co-coder to compare codes and agree on the final themes. ATLAS.ti software was used to assist with data organisation and management.

2.7 Trustworthiness

Trustworthiness was ensured using Lincoln and Guba’s criteria of credibility, dependability, confirmability, and transferability.¹⁴ Credibility was enhanced through prolonged engagement with participants during data collection, audio-recorded interviews, field notes, and member checking to verify the accuracy of participants’ responses and interpretations. Dependability was strengthened by maintaining a detailed audit trail documenting methodological decisions, interview processes, coding procedures, and theme development throughout the study.

Confirmability was ensured through reflexive journaling, bracketing of personal assumptions, verbatim transcription of interviews, and independent co-coding by an experienced qualitative researcher to minimise researcher bias. Consensus discussions between the researcher and co-coder were held to reach agreement on the final themes and interpretations. Transferability was supported through purposive sampling and by providing detailed descriptions of the study setting, participant characteristics, and research processes, enabling readers to assess the applicability of the findings to similar contexts.

2.8 Ethical considerations

Ethical approval was obtained from the University of Limpopo Turfloop Research Ethics Committee (Ref: TREC/1633/2024:PG). Permission to conduct the study was further obtained from the Limpopo Provincial Department of Health, district management, and the management of the participating hospitals.

Participation was voluntary, and written informed consent was obtained from all participants prior to data collection. Participants were informed of their right to withdraw from the study at any stage without penalty. Confidentiality and anonymity were maintained by using participant codes (P1–P16), and all data were stored securely on password-protected devices accessible only to the research team.

3.1. Demographic characteristics of participants

The study included 16 professional nurses working in the psychiatric wards of Donald Fraser and Elim Hospitals in the Vhembe District, Limpopo Province. Participants varied in gender, age, years of psychiatric nursing experience, and specialist psychiatric training, providing diverse perspectives on the assessment and documentation of mental healthcare users (MHCUs). Most participants were female (n = 12), aged between 50 and 59 years, and had extensive psychiatric nursing experience. However, only five participants had formal psychiatric nursing qualifications, while the majority lacked specialised psychiatric training, which participants linked to challenges in conducting comprehensive assessments and accurate documentation of MHCUs.

3.2. Themes and sub-themes

Analysis of the data generated three major themes and seven related sub-themes describing nurses’ experiences of mental healthcare assessment and documentation during admission to MHCUs ( Table 1). The findings are presented with supporting verbatim quotations to preserve participants’ voices and enhance their credibility.

Theme 1: Nurses’ Experiences of Assessment of MHCUs

Participants described mental healthcare assessment as a critical yet complex process requiring nurses to evaluate both psychiatric and physical health conditions during admission. Nurses emphasised the importance of comprehensive assessment in ensuring safe and appropriate management of MHCUs.

3.2.1. Sub-theme 1.1: Physical Observation, Assessment and Management

Participants highlighted that physical assessment formed an essential component of psychiatric admission because certain medical conditions could mimic or exacerbate psychiatric symptoms. Participant 3 (Female, 50–59 years, 11–15 years’ experience) explained that “You need to make sure you check your patient thoroughly, because psychotic symptoms can be caused by underlying issues, for example, confusion from very high blood pressure or low blood glucose.” Similarly, Participant 7 (Male, 50–59 years, 6–10 years’ experience) added that “It is important because we assess the patients mentally and physically; mentally, we want to assess the status of the patient, and physically, we assess for skin integrity, etc., because most of the patients are not fit to be admitted to the mental health care unit.” Furthermore, Participant 9 (Female, 50–59 years, over 21 years’ experience) stressed the importance of comprehensive assessment, stating, “We need to check our patient thoroughly and do a full physical assessment of the mental health care user when they arrive at the hospital.”

3.2.2. Sub-theme 1.2: Involvement of Family Members in the Assessment

Participants described family involvement as essential in facilitating accurate assessment and continuity of care. Nurses explained that family members often provided valuable collateral information regarding patients’ psychiatric history, behavioural changes, and presenting symptoms. Participant 3 (Female, 50–59 years, 11–15 years’ experience) mentioned that “We need to have the contact numbers of patient relatives so that when there is a need, we can phone the relatives to come to give us the other full information concerning the patient.” In support of this, Participant 10 (Female, 50–59 years, 11–15 years’ experience) added that “When we document the patient’s assessment or information, we allow relatives to be present so that they can also know what is going on with the patient, because if they are not present, they might say the patient was beaten at the hospital.” Furthermore, Participant 14 (Male, 60 years and above, over 21 years’ experience) explained that “We also have faithful relatives, and they give us information in a good way, and they help us until we attend to the patient; they give us the true psychotic features that their patient is presenting with, and you feel that they are not lying.”

3.2.3. Sub-theme 1.3: Skills to Ensure a Comprehensive Assessment

Participants emphasised the importance of assessment skills, communication, and clinical judgement in conducting comprehensive mental healthcare assessments. Participant 1 (Male, 40–49 years, 11–15 years’ experience) explained that “During assessment, you need to ask relevant questions so that you can get a clear understanding of the patient’s condition.” Similarly, Participant 5 (Female, 30–39 years, 6–10 years’ experience) highlighted the importance of vigilance and adequate time during assessment, stating that “So, you need to be very vigilant when assessing the MHCU, so that you don’t miss any important information. You need to take a proper history from the relatives and give yourself time when assessing the patient and documenting, because you might otherwise leave out crucial information. Because for you to document everything, you need to give yourself time.” Furthermore, Participant 10 (Female, 50–59 years, 11–15 years’ experience) stressed the importance of listening skills by noting that “When the nurse is taking history, he/she must listen attentively so that he/she does not miss any information that needs to be documented. Listening skills are very important.”

Theme 2: Nurses’ Experiences of Teamwork during Assessment of MHCUs

Participants described teamwork as an important component of mental healthcare assessment because it enhanced patient safety, reduced workload pressures, and improved the quality of patient care.

3.2.4. Sub-theme 2.1: Intraprofessional Teamwork

Participants reported that collaboration among nurses was essential during the admission and management of MHCUs. Participant 5 (Female, 30–39 years, 6–10 years’ experience) explained that “Nurses help each other. Remember, there are many documents involved with MHCU. We normally split the work and share duties, but that depends on the staff coverage because we want to finish in time.” Likewise, Participant 2 (Female, 50–59 years, over 21 years’ experience) added that “Here we work as a team, more especially as we are short-staffed. For example, usually when a patient is coming for admission, we work with that patient as a team.” Furthermore, Participant 14 (Male, 60 years and above, over 21 years’ experience) described how teamwork enhanced efficiency and safety by stating that “Strategies that we normally use, we taught each other to be fast during admission because if you delay, the patient can become aggressive and start destroying property and get injured, so we share duties so that we can finish fast. Everyone in the ward will be involved for that patient so that we can be quick, even with giving the patient medication, so that the patient can rest.”

3.2.5. Sub-theme 2.2: Interprofessional Teamwork

Participants further highlighted the importance of multidisciplinary collaboration during the assessment and management of MHCUs. Participant 2 (Female, 50–59 years, over 21 years’ experience) explained that “Remember when we work, we work as a team; there is a social worker, Occupational Therapist (OT), etc.” Similarly, Participant 3 (Female, 50–59 years, 11–15 years’ experience) stated that “We end up trying to liaise with the multidisciplinary team, we have a team of social workers whom we make sure that we trace relatives as some users are brought by the police officers without close relatives.” Furthermore, Participant 11 (Female, 30–39 years, 2–5 years’ experience) highlighted the role of security personnel and medical staff by noting that “There are security officers in our team to assist with manpower, but if the MHCU is worse or uncontrollable, then the doctor can prescribe something to calm down the patient.”

Theme 3: Nurses’ Experiences of Mental Healthcare Documentation

Participants described mental healthcare documentation as a critical component of psychiatric nursing practice because it supports legal compliance, continuity of care, and monitoring of patient progress.

3.2.6. Sub-theme 3.1: Completion of Legal Documentation

Participants emphasised the importance of accurately completing legal documentation during MHCU admission. Participant 1 (Female, 50–59 years, 11–15 years’ experience) explained that “Filling of MHCA forms is also done at casualty or emergency unitsor Outpatient Departments (OPD), then here in the ward, when we receive these patients, we check the documents if they are properly completed and if they are available.” Similarly, Participant 3 (Female, 50–59 years, 11–15 years’ experience) added that “When a patient arrives, I must ensure their admission complies with the Mental Health Care Act No. 17 of 2002. The patient should have completed the documents from the outpatient department.” Furthermore, Participant 12 (Female, 50–59 years, 11–15 years’ experience) stressed the importance of complete documentation by stating that “So, it’s important to complete the assessment and documentation in full and not miss any information; you might find that the patient is admitted, but when you check you realise that he/she does not fit for admission or admitted under wrong category, voluntary or involuntary admissions etc, so we’re documenting to ensure that indeed the patient fits to be admitted.”

3.2.7. Sub-theme 3.2: Consistent Observation and Documentation

Participants highlighted the importance of continuous patient observation and documentation in monitoring treatment response and ensuring continuity of care. Participant 3 (Female, 50–59 years, 11–15 years’ experience) explained that “Let’s say I have given the patient Serenace, and the patient is starting to have side effects, so it means I have to observe the effect of the medication on the patient. If I find that the patient is experiencing side effects, I might report it to the doctor. We record down, and we also record what the doctor did.” The same participant further emphasised the legal and professional importance of documentation by stating that “You need to make sure that whatever you have observed, you record it because in nursing what is not recorded is not done, so it means that if I observe something, I have to record it down; I have to report to the ward in charge and to the doctor; everything must be written down.” In support of this, Participant 14 (Male, 60 years and above, over 21 years’ experience) added that “We documented what time the patient came, and this was the patient’s problem and the manifestations that we have noted and combined the information from the relatives and documented it. And if the patient has calmed down, we document all the sedations that we have used until they’re effective and place the patient on the bed to rest.”

Implications for practice

The findings highlight the need for ongoing psychiatric training, adequate staffing, and strengthened multidisciplinary collaboration to improve mental healthcare assessment and documentation in rural psychiatric settings. Standardised assessment and documentation tools, supportive supervision, and regular clinical audits may enhance compliance with legal and professional standards while improving continuity and quality of care. The study further emphasises the importance of staff wellness initiatives to reduce occupational stress and burnout among nurses working in resource-constrained psychiatric environments.

Study limitations

This study was conducted in two rural referral hospitals in Limpopo Province, which may limit the transferability of the findings to other settings. The study included only professional nurses, excluding perspectives from other multidisciplinary team members involved in mental healthcare. Participants may also have provided socially desirable responses during interviews. Although measures such as reflexive journaling and independent coding were used to minimise bias, the researcher’s professional background in nursing may have influenced data interpretation. Furthermore, the study relied solely on interview data without triangulation through observations or document reviews. Future studies should include multiple settings, multidisciplinary perspectives, and additional data collection methods to strengthen the understanding of mental healthcare assessment and documentation practices in resource-constrained environments.