Government has made significant efforts to improve the psychiatric wards over the past decade. But the main refrain remains acute staff shortages.
In an effort to reintegrate psychiatric patients with commuities, and to cut costs, government has embarked on a programme of ‘deinstitutionalisation’. This essentially means sending stable psychiatric patients back to their families ‘ in the few instances where their families will have them back.
But in many cases, the policy has backfired. Families cannot cope. Many psychiatric patients stop taking their medication and end up being hospitalised.
In another policy change aimed at keeping patients out of long-term care, hospitals are obliged to keep psychiatric patients in short-stay wards to see whether they can stabilise them rather than sending them to psychiatric hospitals.
But many healthworkers do not know how to treat these patients.
At the otherwise well run Kimberley Hospital, a psychiatric patient was abused by a nurse in front of me and it was treated as a laughing matter by staff.
The patient, a known psychiatric case who had become psychotic, had been admitted for 48 hours’ observation. He woke up from a bad dream and bolted out of the hospital wearing only a backless hospital-issue top.
After a long chase, security guards caught up with him at the taxi rank about 2km away and dragged him back like a criminal. The sister in charge of the ward, a heavy woman with a limp, ordered the security guards to put him in a small lock-up room, then borrowed a baton from one guard.
She went into the room and poured out a torrent of abuse on the patient. This was punctuated every few seconds by the sound of the baton being brought down hard and the groans of the patient.
After about five minutes, the sister came out sweating and heaving with exertion. The guards and nurses laughed, the sister moved back to her station and no one even thought to look in on the patient.
Prejudice against psychiatric patients, who of whom cannot report abuse, is ingrained and will take years to eradicate.
Jeannette*, a slender young woman with squint eyes, tries to shuffle out through the security gate behind us, but is roughly restrained by a stocky woman who puts a heavy forearm around Jeannette’s neck and pulls her back.
When I remark that the security guard seems unnecessarily zealous, I am told that the stocky woman is an auxiliary nurse.
‘They get like that after a while,’ says Cynthia Isaacs, head of psychiatric services in the Northern Cape. ‘The ward is understaffed and some staff members have been threatened by patients here in the acute wards.’
Only one professional nurse and one auxiliary are in charge of the 13 women in the acute ward of West End Psychiatric and TB Hospital in Kimberley, the province’s only in-patient facility for psychiatric patients.
A short distance away in the male acute ward, there are 19 patients. There, one professional nurse and two nursing assistants are in charge and the patients sleep together in dormitories.
Yet the acute wards are where the most disturbed patients are kept, and where escape attempts and attacks on staff and other patients are fairly common.
The male patients stand or squat in the orange dust of a tiny courtyard, most smoking ‘ one of the major preoccupations of institutionalised psychiatric patients.
There is precious little else for the patients in the acute wards to do. The men can no longer watch television as there are not enough nurses to watch those in the TV room and those in the courtyard.
‘We need three professional nurses in this ward alone. But no one wants to work in psychiatry. It’s a scarce skill but this is not recognised,’ says Mrs Evelyn Goeieman, who manages the 107-bed hospital.
There are many other difficulties, some practical. Patients’ food is sent over from Kimberley Hospital. But, says Goeieman, it is never enough.
‘The medication that our patients are on makes them hungry and our patients are also active. But they get the small helpings of ordinary sick patients. It is not enough,’ she says.
The hospital is on a dirt track at the far end of town, together with a handful of patients with multi-drug resistant TB.
It’s an ‘out of sight, out of mind’ kind of place ‘ and some of the psychiatric patients have been there for 40 years, long abandoned by their families. Even getting through by telephone is difficult as there is no switchboard operator.
Stable patients are transferred from the acute to the chronic wards where they have much more freedom.
A handful of severely depressed and suicidal patients are in West End voluntarily, and are kept together in open dormitories. They usually stay for a two or three weeks and although they are free to walk around, most choose to lie quietly on their beds.
Those psychiatric nurses who work at West End are highly skilled but because of the staff shortages they are only able to do ‘the critical things’, says one who asks not to be named. There is no time to run group therapy sessions for the patients.
The province only has two psychiatrists buts, says Isaacs with a twinkle in her eye, this is a 100% improvement as for years the province has had only one psychiatrist.
There are about 6 000 known psychiatric patients in the province, and the psychiatrists try to see every patient once a year, says Isaacs. Stable patients are treated at clinic level, where they get their medication.
There is hope for the West End patients, however. A new psychiatric hospital is being built to replace the grim hospital, and the first patients are expected to be admitted in 2008.
* not her real name.
Despite a desperate need for facilities for psychiatric patients, Fort Napier Hospital in Pietermaritzburg is operating way below capacity because it simply lacks the staff to admit more patients.
Although the facility has 370 beds, serious staff shortages have forced management to reduce patient numbers to about 280, says the superintendent, Dr Sharma Jogessar.
The hospital is operating with less than a third of staff that it needs. There are 143 vacancies, mostly for professional nurses, and a total staff complement of 62.
Psychiatric nurses are highly prized in developed countries, and many of Fort Napier’s experienced staff have left for Britain and Saudi Arabia.
‘This is demoralising for those who remain behind because they have to double up on the work,’ says Matron Tholakele Madlala, who heads the nursing staff.
At least 60% of Fort Napier’s patients are state patients, the majority of whom have been certified as mentally unfit to stand trial after murdering or raping.
The most common illnesses the patients suffer from are schizophrenia and bi-polar disorder.
As the vast majority of patients are male, there is a particular need for male nurses, especially in the closed forensic ward. This is where suspects are sent for 30 days’ observation before the courts rule on whether they are mentally fit to stand trial.
‘Some of these patients are very volatile because they are unmedicated and not on treatment while under observation,’ says Jogessar.
From 5.30pm to 7am, the men ‘ dressed in orange pants and light blue tops ‘ are confined in single rooms furnished with only a bed and a potty. Their days are spent in a courtyard surrounded by electric fencing.
Sipho Mbongwa, who heads the closed forensic ward, says that while patients are often aggressive, they are seldom violent.
‘I have worked here for 34 years and I have never been attacked by a patient. The staff understand how to handle them.’
When patients fight, perhaps twice a month, it is usually over cigarettes.
Given the shortages, and the fact that the place needs renovations, the ward cannot cope with more than 20 patients at a time.
‘There are about 90 men on the waiting list and we are booked up for the next three months,’ says Jogessar.
Two dazed-looking boys suspected of rape were being admitted for observation when Health-e visited the hospital.
‘There is a big problem because we don’t have facilities for children and adolescents, even for the mentally retarded,’ said Jogessar. They were admitted to a female ward.
After 30 days’ observation, the court rules whether the men are mentally fit to stand trial, based on the recommendations of state doctors.
If declared unfit, they are returned to Fort Napier ‘ this time to the forensic security wards. There they usually spend about three months where they are put on treatment and stabilised.
Zakhele Ngubane, head of 9B, the forensic security ward, says patients ‘can be unpredictable because they think they can be discharged and get aggressive because they want to go home’.
‘We have to sit and explain the situation and their treatment to them.’
While no women nurses are allowed to work at night, staff shortages mean that some women nurses have to work in 9B during the day.
Sister Thobile Njokweni is the lone female nurse on duty when I visit, and admits it can be tough being the only woman in the environment.
‘The patients try to touch you, and they say things like ‘won’t it be nice if I touch your breasts’. Others want special attention,’ says Njokweni. ‘I have to be with a male nurse at all times.’
Njokweni says she has always had an interest in psychiatric nursing, stemming from childhood when some of her relatives were mentally ill. ‘They are human beings too,’ she says.
A number of patients hover nearby as I speak to Njokweni, one who keeps trying to intervene, insisting that I am ‘Phyllis’ and another who mutters that he ‘doesn’t trust this place’.
Others listen to the radio, play cards, watch TV and sometimes get taken to a soccer field for a game. And smoking is always a favourite pastime.
From 9B, based on their behaviour and response to treatment, high-functioning patients can progress to semi-open wards and then open wards, where they have the freedom to roam the grounds of the institution and attend occupational therapy sessions.
Dagga smoking and smuggling is a big problem
After 10 to 15 years, some state patients could be discharged by a judge, either unconditionally or into the care of the families. But, says Jogessar, this seldom happens as their families are often afraid of them.
‘Rehabilitation is one of our biggest problems because families often don’t want them back.’
A non-distinct, narrow security gate and a sign with rules for visitors are the only indication that the steel gate is the entrance to the high-walled yellow face-brick building, or more specifically, Valkenberg Hospital’s infamous ward 20.
While hospital staff and provincial government officials are at pains to point out that it is a hospital, the wards resemble a prison with bleak buildings, body searches of visitors, sounds of clanging steel gates and burly security guards.
Staff are also quick to point out that the stark rooms accommodating some of South Africa’s most violent criminals ‘ mostly murderers and rapists ‘ are a huge improvement to the previously overcrowded and filthy wards.
The Western Cape Health Department has spent money on painting the buildings, improving security to protect staff, revamping the bathrooms and installing heating systems. This is all an interim measure as a new ‘forensic village’ will be built nearby in the next few years.
Ward 20 currently holds 50 patients of which 35 are state patients while 15 are on trial and have been referred by the courts for observation.
‘They (the state patients) are kept here because they are not the nicest people you would want to meet,’ says Valkenberg psychiatrist Dr Larissa Panieri-Peter.
Because of the small number of beds (determined by the number of available staff), prisoners referred by the courts for observation have to wait 12 months for a bed.
There are currently 100 people on the waiting list. The new hospital, which will be completed by 2010 will have 60 observation beds.
Referred patients are observed for a maximum of 30 days and a report is submitted to court, stating whether the person is fit to stand trial ‘ 30 percent of referrals are assessed as not able to face the justice system.
Ward 20 was constructed around a paved courtyard where most of the men lie stretched out sleeping in the sun. One or two men pace up and down while there is a room where voluntary occupational therapy takes place.
Panieri-Peter conceded that the bleak conditions are far from ideal, but considerably better than before the renovations took place.
Staff shortages are a constant problem with two professional nurses, three assistant nurses and one staff nurse on a shift to care for the 50 patients.
Panieri-Peter points out that ‘a very specific person’ is required to work in Valkenberg and that it is not easy to attract staff to Valkenberg..
‘You need high quality nursing staff,’ she adds.