Nurses' experiences during assessment and documentation of mental healthcare users during admission at selected hospitals of Vhembe District, Limpopo Province

Abstract

Background: The nursing assessment and documentation process for mental health care users is a critical component of mental health care, playing a significant role in ensuring patient safety, appropriate treatment planning, and overall quality of care. However, there are times when the nursing assessment is not well documented, which has an impact on the mental health care user's quality of care. Purpose: The study aims to determine the nurses’ experiences during the assessment and documentation of MHCUs during admission at selected hospitals of Vhembe District, Limpopo Province. Research Methods: The study utilised a qualitative design that was explorative, descriptive, and contextual. A non-probability purposive sampling method was used to sample the nurses at the selected hospitals of the Vhembe District. Data was collected through semi-structured one-on-one interviews using an interview guide, and data was analysed using Tesch’s open coding method. Ethical considerations and measures to ensure trustworthiness were followed throughout the entire study. Results: The study findings highlighted six themes that emerged, including nurses’ experiences of assessment of MHCUs, nurses’ experiences of teamwork during assessment of MHCUs, nurses’ experiences of mental healthcare documentation, nurses’ experiences of assessment of and documentation of MHCUs, nurses' challenging experiences of assessment of MHCUs, and nurses’ recommendations to improve assessment and documentation of MHCUs. Recommendations: The nurses' experiences during assessment and documentation of mental healthcare users during admission revealed that nurses face the complexity of physical and psychosocial assessment, the role of family involvement, the need for clinical expertise, and the value of both intra- and interprofessional teamwork. The mandatory requirement of completing the MHCA forms, continuous observation, and documentation. Barriers included limited resources, staff shortages, and difficulty in managing aggressive patients. Despite these challenges, nurses highlighted the importance of thorough documentation for legal protection, care planning, and accountability. Adopting and implementing the recommended solutions can improve the assessment of MHCUs and foster better care.