Study Site

The study was performed at an acute care public sector psychiatric institution in the Nelson Mandela Metropole, in the Eastern Cape province of South Africa. The site has bed space for a maximum of 163 patients, though it is possible to extend this space by a further 30 patients in times of high influx. Thus the maximum space for patients is 193 at any given time. Both male and female patients are treated at the site. Patients are designated to one of six different wards depending on their gender, age, current mental health status and physical health status (Figure 3.5). Patients will remain in the psychiatric institution for no less than one week, after which they may be allowed weekend leave, a leave of absence or may be discharged. According to the clinical head of the hospital, the average length of stay for a patient is between one and three months. However, in rare cases patients have been known to stay for extended periods of up to a year in length.

73 Figure 3.5

Flow of patients through the study site from admission to discharge, including possible inter-ward movements and types of patients in each ward. Double sided arrows indicate cases in which patients may move back and forth between the two relevant wards depending on the severity of their current mental illness. *Difficult/dangerous patients requiring a higher degree of care.

WARD B

WARD A

Male adolescents, males and females older than 65 years,

patients with co- morbidities

Stabilising/fully stabilised male adolescents or elderly patients or patients

with co-morbidities Female adults Female adolescents Stabilising or fully stabilised female patients

WARD D

ADMISSION

WARD E

WARD C

WARD D

WARD F

DISCHARGE

Fully stabilised male patients

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3.3.1 Ward A.

Ward A is also known as the 'acute female ward' (Figure 3.5). It has 27 beds available at maximum, with no room for extension. Patients housed in this ward will typically be between the ages of 12years and 60 years. Females who are floridly psychotic or currently experiencing severe phases of mood disorders are housed in this ward.

3.3.2 Ward B.

Ward B is also known as the 'medical ward' (Figure 3.5). This ward houses male and female patients in separate areas. This ward is typically reserved for patients who are: elderly; males under the age of 18 years (females below the age of 18 remain in ward A); or who experience medical co-morbidities in addition to their index condition. Patients who are also considered to be vulnerable or at risk of being antagonised by other patients may also be housed in this ward. Vulnerable patients include intellectually disabled patients, and those patients returning from electroconvulsive therapy (ECT).Ward B has 30 beds available. The number of beds in ward B is not extendable, due to the nature of the care required for adolescent and elderly patients.

3.3.3 Ward C.

Ward C is also known as the 'sub-acute male ward' (Figure 3.5). It houses male patients who are typically between the ages of 18 years and 60 years. Patients will be sent to this ward from ward E (Section 3.3.5) after their psychosis has stabilised to a reasonable degree. It has 37 beds available at maximum, with no room for extension.

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3.3.4 Ward D.

Ward D is also known as the 'psychiatric intensive care unit', and is typically reserved for extremely high-risk or problematic patients (Figure 3.5). There are a total of 6 beds in the ward, as well as one private bedroom (used exclusively for patients who cause problems with other patients in the ward). The number of beds may not be extended. The purpose of this ward is to provide a higher level of care for patients with a ratio of at least one nurse to one patient. Ward D also serves the purpose of the admission ward: patients who are received at the site of study will be assessed and interviewed by an admitting doctor, as well as a registered nurse in ward D. From there the patient will be allocated to the most appropriate ward for their treatment, typically one of wards A, B or E (Sections 3.3.1; 3.3.2; 3.3.5 respectively).

3.3.5 Ward E.

Ward E is also known as the 'acute male ward' (Figure 3.5). It houses only male patients, who are typically between the ages of 18 and 60, similar to ward C (Section 3.3.3). This ward has 32 beds available, which may be extended to approximately 60 beds in times of high mental health care patient influx. However, this is used only as a worst case scenario, as increasing the number of beds in the ward decreases patient comfort and has proven to be problematic in the past. As this is the ward designated for acutely ill patients only those patients who are currently psychotic or currently experiencing episodes of mood disorders will be housed in this ward. Once a patient in ward E has stabilised to a degree where they are considered safe for a different setting they will be transferred to the next most appropriate ward.

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3.3.6 Ward F.

Ward F is also known as the 'pre-discharge ward'. It is reserved for patients who have been stabilised in one of the other wards, and is used as a final point before their discharge (Figure 3.5). This ward has 31 beds available, with no room for extension. Male and female patients are housed together in this ward, with sleeping quarters in separate dormitories for each gender. Part of the purpose of this ward is to promote patient participation in activities that will prepare them for life outside of the hospital. As such patients do their own washing and cleaning in this ward, and participate in the preparation and serving of meals.