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

Abstract

Background Mental healthcare assessment and documentation are essential components of psychiatric nursing practice, particularly in rural resource-constrained settings where nurses often manage mental healthcare users (MHCUs) with limited specialist support. In South Africa, shortages of psychiatric personnel, inadequate training, and high workloads may compromise the quality of assessment and documentation during psychiatric admissions. Objective This study explored nurses’ experiences of mental healthcare assessment and documentation during the admission of MHCUs in selected rural referral hospitals in Limpopo Province, South Africa. Methods A qualitative exploratory-descriptive contextual design, guided by Orlando’s Deliberative Nursing Process Theory and Donabedian’s Structure–Process–Outcome Model, was employed. Sixteen professional nurses working in psychiatric units at two rural referral hospitals were purposively sampled. Data were collected through semi-structured individual interviews conducted between May and July 2025 and analysed using Tesch’s open-coding method. Trustworthiness was ensured through reflexive journaling, member checking, independent co-coding, and an audit trail. Results Three themes emerged: experiences of mental healthcare assessment, teamwork during psychiatric admissions, and mental healthcare documentation practices. Participants described assessment as a complex process requiring integrated physical and psychiatric evaluation, effective communication, and family involvement. Intra- and interprofessional teamwork were viewed as essential for managing staff shortages, patient aggression, and workload pressures. Participants further highlighted challenges related to repetitive legal documentation, inadequate psychiatric training, and limited staffing, which negatively affected assessment and documentation practices. Accurate documentation and continuous patient observation were perceived as important for patient safety, continuity of care, and compliance with the Mental Health Care Act No. 17 of 2002. Conclusion Mental healthcare assessment and documentation in rural psychiatric settings are influenced by organisational constraints, workforce shortages, and legal requirements. Strengthening psychiatric nursing training, multidisciplinary support, staffing, and documentation systems may improve the quality and safety of rural mental healthcare services.