Psychiatric nurses’ perceptions and experiences working in a psychiatric institution during the COVID-19 pandemic in Gauteng Province, South Africa

Abstract

Background

Despite evidence of COVID-19’s impact on healthcare workers, there is limited documentation on psychiatric nurses’ perceptions and experiences working in psychiatric institutions in Gauteng Province during the pandemic. The study aimed to explore and describe psychiatric nurses’ perceptions and experiences working in a psychiatric institution during the COVID-19 pandemic.

Method

A qualitative, exploratory, descriptive, and contextual design was employed to explore psychiatric nurses’ perceptions and experiences working in a psychiatric institution during the COVID-19 pandemic, utilising in-depth individual interviews. Data were collected from a specialised tertiary academic psychiatric hospital in Gauteng Province, South Africa, between 23 March and 12 September 2023. Ten participants were interviewed. Colaizzi’s seven-step method was used to analyse the transcribed interviews.

Results

Four themes and various sub-themes emerged from the interviews: confronting the reality and fear of COVID-19; the psychiatric nurses were not adequately prepared to care for individuals with COVID-19; COVID-19 increased their workload and experienced that it impacted their health negatively; and based on their experiences, psychiatric nurses offered valuable insights that can inform better management strategies for future pandemics in similar environments.

Conclusion

This study reveals that South Africa’s psychiatric nurses faced the COVID-19 crisis from a position of vulnerability. The findings highlight how pre-existing burdens, such as poor infrastructure, a lack of equipment, and staff shortages in the South African healthcare system, were amplified during the COVID-19 pandemic, placing pressure on psychiatric nurses.

Background

In December 2019, a novel coronavirus, SARS-CoV-2, emerged in Wuhan, China, and soon escalated into a global pandemic known as COVID-19 [1]. This unforeseen global crisis impacted all economic sectors, with healthcare workers facing extreme challenges due to overwhelmed healthcare systems. The pandemic, therefore, had a significant impact on the mental well-being of healthcare professionals worldwide [2].

Globally, healthcare workers in countries like the United Kingdom reported increased stress, burnout, and mental health struggles due to the pandemic’s demands [5]. Local contexts, such as the unique healthcare system in South Africa, provided important insights into how psychiatric nurses were specifically impacted [3]. Ultimately, the COVID-19 crisis exacerbated pre-existing challenges within South Africa’s mental health services, including resource shortages and high patient-to-nurse ratios, making the situation even more demanding [4].

According to Akkuş et al. [6] nurses experienced high levels of stress during the COVID-19 pandemic. In addition to fears of transmitting the disease to patients and limited personal protective equipment (PPE), psychiatric nurses also had limited knowledge and resources to care for psychiatric patients with COVID-19 [7]. The pandemic thus created significant challenges for nurses, especially for those working in psychiatric institutions where resources were already limited. While much research has focused on the experiences of healthcare workers in general, the unique challenges psychiatric nurses faced in caring for patients with both mental health conditions and COVID-19 have not been thoroughly explored [8]. Psychiatric nurses in these settings were tasked with managing patients with complex mental health needs while also addressing the physical health challenges posed by the virus. Therefore, the pandemic ultimately exposed the strain on healthcare systems, particularly in psychiatric institutions where resources to care for physically unwell patients were inadequate [9]. The absence of sufficient mental health support and resources for psychiatric nurses during the pandemic led to increased stress, burnout, and a decline in this population’s mental well-being [10].

Moreover, psychiatric institutions were required to modify their practices in response to COVID-19 to meet increasing safety demands and ensure patient well-being. These safety measures significantly altered the environment for psychiatric inpatients, making it difficult to maintain a therapeutic atmosphere and contributing to greater mental health challenges among staff and patients [11]. Recent studies have shown that psychiatric nurses can actively build and strengthen their resilience in managing workplace stressors and challenges. They do so by rapidly adapting to the changing landscape of care provision [12]. This study therefore explored the perceptions and experiences of psychiatric nurses who worked under these conditions, providing insights into how they managed their dual roles of caring for patients with mental illnesses and COVID-19 [13]. To the best of the researchers’ knowledge, there is no literature exploring the perceptions and experiences of psychiatric nurses in Gauteng Province, in South Africa. Therefore, the study sought to fill a gap in the literature and inform future strategies to support psychiatric nurses and improve care in psychiatric settings during pandemics.

Methods

Study design

A qualitative, exploratory, descriptive, and contextual research design was used in this study to gain a deep understanding of psychiatric nurses’ perceptions and experiences during the COVID-19 pandemic [14]. This approach was chosen because it allowed for an in-depth exploration of their personal feelings, challenges, and coping mechanisms in their own words, which is essential given the limited existing research on this topic [15]. Throughout this study, the authors followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) to report on the qualitative findings [16].

Setting

The research setting was a specialised tertiary academic psychiatric hospital in Gauteng Province, South Africa. This hospital admits patients under the Mental Health Care Act No.17 of 2002. It boasts 18 wards, three of which cater to acute psychiatric patients and 15 to forensic psychiatric patients. This setting was chosen because it specialises in psychiatry and because it employs psychiatric nurses who are participants in this study. The hospital can accommodate 760 patients. The capacity of each ward differs but ranges from 15 to 70 patients. Seventy-four psychiatric nurses were employed by this hospital in 2023, and participants for this study were sourced from its acute and forensic units.

Population and sample

The population for this study consisted of psychiatric nurses who had been working in a tertiary psychiatric hospital in Gauteng Province between December 2019 and 2023. Purposive sampling involves researchers intentionally selecting participants who possess specific knowledge or experience related to the research phenomenon [18]. In this study, psychiatric nurses were chosen because they had the qualifications, experience, and insights needed to answer the research questions. The purposive sampling strategy ensured that the study focused on the most relevant individuals who met specific criteria relevant to the study’s objectives. Participants were ultimately psychiatric nurses who met predetermined criteria for participation. The criteria for inclusion were participants who had been employed in a tertiary psychiatric hospital in Gauteng Province, had to have a psychiatric nursing qualification and be registered as professional nurses with the South African Nursing Council (SANC), have two to three years of experience working in a psychiatric institution and be willing to participate in the study.

Participants were recruited through individual outreach strategies, where the researcher approached all potential participants personally to explain the study and invite them to participate. The final sample consisted of 10 psychiatric nurses, which was sufficient to reach data saturation since no new information or themes emerged from the data [19].

Data collection

The researcher is a skilled interviewer and conducted 10 face-to-face, in-depth, individual interviews between 23 March and 12 September 2023. The central question posed to participants was, “How was it for you, working in a psychiatric hospital during the COVID-19 pandemic?” The researcher led the process of gathering information from participants using semi-structured interviews and observations. Each interview lasted 45 min to one hour, allowing participants to share their experiences in detail. No repeat interviews were conducted, and data saturation was achieved by the 10th participant, indicating that no new information or themes emerged from the subsequent interviews [21]. Field notes were also recorded within 24 h of each interview to capture additional observations and reflections. Individual interviews were audio-recorded and transcribed verbatim; transcripts were then returned to participants for review, comments, corrections, and approval. The participants returned the transcripts to the researcher within two weeks and approved the accuracy of the transcripts with no comments or corrections.

Data analysis

Collaizi’s descriptive phenomenological data analysis method was used to analyse the data and develop four main themes and associated sub-themes. This method focuses on understanding participants’ lived experiences by identifying patterns and meanings in the data [22]. The analysis followed a structured process. First, the researcher familiarised themselves with the data by carefully reading and reviewing all the interviews. Significant statements related to the research question were then extracted, and their meanings were formulated in the context of the participants’ experiences. These meanings were organised into clusters to form themes and sub-themes that reflected the core aspects of the participants’ experiences. Using these themes, a clear and detailed description of the phenomenon was developed. Participants were also consulted to validate the findings and ensure they accurately captured their experiences.

Four themes and various sub-themes emerged from the interviews, presented in Table 1: (a) Working in a psychiatric hospital during COVID-19 was challenging and overwhelming; (b) Psychiatric nurses’ readiness to care for persons with COVID-19; (c) The impact of COVID-19 and the burden of care; and (d) Recommendations to manage future pandemics.

Table 1.

Themes of nurses’ perceptions and experiences working in a psychiatric institution during the COVID-19 pandemic in Gauteng

Themes	Sub-themes
Theme 1 Confronting the reality and fear of COVID-19	a) The realisation that COVID-19 is real b) Aligning patient safety with quality care c) Resource availability and supplies
Theme 2 Psychiatric nurses’ readiness to care for persons with COVID-19	a) Uncertainty and frustration regarding the provision of nursing care b) Perceived lack of support from management
Theme 3 The impact of COVID-19 and the burden of care	a) Mental health of staff members b) Frustration with COVID-19 protocols and policies c) Fear of working in COVID-19 units and contracting the virus
Theme 4 Recommendations to manage future pandemics	a) Mental health of staff and their involvement in decision-making b) Clearer communication and information sharing c) Staff training d) Provision of resources e) Evidence-based research to guide practice

Source: Mkhwanazi (2024:55) [20]

Measures of trustworthiness

The researcher was an experienced mental health nurse and operational manager in a psychiatric unit when the study was conducted in fulfilment of her master’s degree in Psychiatric Mental Health Nursing. The researcher was acquainted with the participants, practised reflexivity throughout the research processes, and was aware of their personal experiences and potential bias related to the research phenomenon. The researcher employed bracketing by setting aside their own preconceptions to reduce bias and engaged in peer briefing, where discussions were held with the research supervisors. An independent coding expert also performed data coding. To enhance the trustworthiness of the analysis, an independent coder with a PhD in mental health nursing and seven years of experience in qualitative data analysis was involved in reviewing the data and themes, ensuring consistency and reducing potential bias. These experiences and potential biases were documented before and during the data collection phase, so the researcher remained aware of them during data analysis [17].

According to Adler [23] trustworthiness in research ensures that the study’s findings are reliable, accurate, and credible. In qualitative research, this means ensuring that the results accurately reflect the participants’ experiences. The researcher focused on four key areas to achieve trustworthiness in this study: First, credibility ensures the findings are truthful and entails researchers checking in with participants and using different data sources or methods to verify their results [24]. The researcher compared the research findings to those of previous studies. Second, transferability provides sufficient detail about the study so that others can judge whether the results are relevant to their own situations. The researcher thus offered descriptions of the participants’ demographic information and quoted responses to promote the study’s transferability. Third, dependability involves keeping clear and consistent records of the research process so others can follow it. The researcher provided a detailed description of the research methodology. Fourth, confirmability ensures that the findings are based on the data provided by participants, rather than the researcher’s personal opinions or biases. The researcher, study supervisors, and the independent coder analysed the data separately and discussed the findings until they reached an agreement.

Ethics

This study was conducted in accordance with the Declaration of Helsinki. Ethical principles were carefully followed throughout the study to protect the participants and ensure the research was conducted fairly. Written and verbal consent was obtained from the participants before interviews commenced. Respect for participants was shown by getting their informed consent before the study began. They received clear information about the research, including its purpose, what would be required of them, and their right to withdraw at any time without any negative consequences. Beneficence was applied by making sure the study was designed to benefit both the participants and the body of knowledge while minimising any risks or harm to those involved [25]. Justice was upheld by selecting participants fairly and avoiding any form of exploitation, with all participants treated equally [26]. Confidentiality was maintained by securely storing the data and keeping the participants’ identities anonymous, so their personal information was protected [27]. The collected data will be destroyed five years after the study’s completion.

Results

Ten participants volunteered to participate in the study. They were between 30 and 53 years old and able to communicate in English. They were all registered as professional nurses with the SANC. Six female and four male participants, aged 30 to 53, took part in the study. Six participants held a diploma in Nursing (General, Psychiatric, Community) and Midwifery, one had a postgraduate diploma in Advanced Psychiatric Nursing, one had a master’s degree in Psychiatric Mental Health Nursing, one had a BTech in Nursing Science, and one had a doctorate in Psychiatric Nursing and Mental Health. Seven paticipants were professional nurses, two were operational nursing managers, and one was a professional nurse acting as an operational manager. Their years of experience as psychiatric nurses ranged from 4 to 33 years. The participants’ characteristics are presented in Table 2.

Table 2.

Participants’ characteristics

Participant no	Qualification	Position held	Years of experience as a psychiatric nurse
1	BTech Nursing Science	Professional Nurse	5
2	4-year nursing diploma	Professional Nurse	4
3	Advanced psychiatric nursing	Professional Nurse	8
4	DCur	Operational Nursing Manager	23
5	4-year nursing diploma	Professional Nurse	9
6	Master’s in psychiatric nursing science	Professional Nurse (Acting- Operational Nursing Manager)	33
7	4-year nursing diploma	Operational Nursing Manager	21
8	4-year nursing diploma	Professional Nurse	26
9	4-year nursing diploma	Professional Nurse	7
10	4-year nursing diploma	Professional Nurse	19

Source: Mkhwanazi (2024:52) [20]

Theme 1: confronting the reality and fear of COVID-19

Psychiatric nurses faced numerous challenges and found it overwhelming to manage their responsibilities while working in a psychiatric hospital during the COVID-19 pandemic.

1. The realisation that COVID-19 is real

Psychiatric nurses realised that COVID-19 was a serious and real threat, which caused fear for many of them. Additionally, psychiatric nurses realised that caring for psychiatric patients became significantly more difficult. One participant shared:

It wasn’t so much alarming at first, but as the numbers grew … we understood that the number of people who are dying with COVID are increasing. We had also COVID ward in the hospital so from my side, I started to realise that COVID is real from that time (Participant 1, 30-year-old male psychiatric nurse).

Another participant said:

So, it was really, it was it was challenging, it was scary. Caring for the psychiatric patient became a little bit more difficult than it is (Participant 4, 49-year-old male psychiatric nurse).

The above direct quotation indicated that the psychiatric nurse was uncertain, overwhelmed and experienced challenges in caring for psychiatric patients under the strict COVID-19 regulations.

• b)Aligning patient safety with quality care

Participants were trying to maintain patients’ physical health and safety while meeting their overall healthcare needs. However, challenges arose due to patients’ limited understanding, restrictions on in-person interactions, and increased feelings of isolation. These factors made it difficult for nurses to create therapeutic environments that complied with COVID-19 regulations. Participants also spoke about the challenges in helping these patients understand the importance of safety measures, which added another level of complexity to their care. One participant shared:

Nursing the patients became harder, because I was nursing patients that are intellectually disabled and they required a lot of explanation with all the changes that were happening at the hospital. (Participant 3, 31-year-old female psychiatric nurse).

Another participant shared her concern for patient safety as indicated in the following direct quotation:

Working with patients who didn’t believe in the pandemic was very challenging and unsafe. Some of them refused to wear masks and didn’t follow safety protocols, putting both themselves and the staff at risk of infection. (Participant 9, 31-year-old female psychiatric nurse).

These direct quotations indicate the challenges the psychiatric nurses faced working with the mental health patients, who are mostly not in touch with reality to understand COVID-19 and its dangers.

• c)Resource availability and supplies

The participants described the psychiatric hospital’s under-resourced and unprepared state to handle the challenges COVID-19 created. The shortage of psychiatric nurses became a serious problem when staff members contracted COVID-19. The hospital is a psychiatric hospital, which means it didn’t have adequate equipment to cater for patients who suffered from COVID-19. The availability and sizes of supplies was a great concern. Participants expressed feeling unsupported by management during the pandemic. This feeling raised concerns about the overall well-being and efficiency of hospital operations during such difficult times. One participant stated:

We were not fully prepared for the pandemic, and there was a shortage of personal protective equipment (Participant 5, 37-year-old female psychiatric nurse).

Another participant shared the lack of personal protective equipment during the pandemic and his concern about the safety of the patients as indicated in the direct quotation below:

There was a time when we had a shortage of masks, and we had to reuse them, which was not safe… but there were some incidents where patients and staff were potentially exposed because we didn’t have enough PPE. (Participant 8, 50-year-old male psychiatric nurse).

Theme 2: psychiatric nurses’ readiness to care for persons with COVID-19

This theme highlighted that psychiatric nurses were not adequately prepared to care for individuals with COVID-19 in a psychiatric hospital setting.

1. Uncertainty and frustration regarding the provision of nursing care

Providing nursing care in a psychiatric hospital became more difficult as COVID-19 caused uncertainty and frustration. The unique challenges required thoughtful adjustments to ensure that psychiatric patients received both effective and compassionate care. One psychiatric nurse explained:

At some time, we didn’t know whether to send patients to other wards which were said to be COVID-19 wards, or we have to keep them in our side room or we have to separate them or isolate them ourselves … So, at some point it became or bring that confusion towards the staff (Participant 1, 30-year-old male psychiatric nurse).

This direct quotation shows that the unplanned and sudden changes within the hospital setting were frustrating and stressful for the participants.

• b)Perceived lack of support from management

Participants expressed feeling unsupported by management during the pandemic. This feeling raised concerns about the overall well-being and efficiency of hospital operations during such difficult times.

It was not as much as I expected, management did not communicate expectations clearly to nurses during the pandemic … I feel like they showed very little to no support at all for nurses during the pandemic. (Participant 3, 31-year-old female psychiatric nurse)

Psychiatric nurses also reported that hospital managers had a fear of contracting the virus. They explained:

I feel like the support from hospital management was quite lacking. They weren’t available to enter the isolation areas where positive patients were kept (Participant 10, 46-year-old female psychiatric nurse)

The lack of support from hospital managers was deeply concerning as it seemed that the participants were alone during the COVID-19 pandemic.

Theme 3: the impact of COVID-19 and the burden of care

Participants shared their experiences during the COVID-19 pandemic, highlighting the lack of support, frustration with COVID-19 protocols and policies, and the fear of contracting the virus.

1. Mental health of staff members

Psychiatric nurses emphasised the importance of better support and access to protective gear to alleviate the stressful situations everyone faced. The lack of adequate support and protective measures likely contributed to higher levels of stress and anxiety among staff, ultimately impacting their health.

This was very stressful for everyone involved, and it could have been avoided with better support and access to protective gear. (Participant, 8-50-year-old male psychiatric nurse).

Another participant mentioned that burnout and panic were significant challenges for psychiatric nurses. This suggests that the participants may have been overwhelmed during the pandemic, leading to emotional exhaustion and heightened levels of anxiety.

Burnout and panic were real challenges. Teamwork played a crucial role in supporting each other during this difficult time, but, our management’s approach wasn’t very helpful. They seemed to be imposing the almost impossible for us, …Such things added to the stress (Participant 9, 31-year-old female psychiatric nurse).

• b)Frustration with COVID-19 protocols and policies

Participants expressed frustration with the ever-changing COVID-19 protocols and policies. They struggled to keep up with the frequent updates and adjustments throughout the pandemic. The constantly shifting guidelines created confusion and increased pressure in an already challenging work environment. These frustrations among psychiatric nurses highlight the importance of promoting clear and consistent communication about COVID-19 protocols to safeguard both patients and healthcare providers. One participant said:

It was frustrating to constantly adjust our routines to follow these guidelines and maintain safety … Initially, it was a bit overwhelming as the regulations kept changing. Different hospitals had different approaches, causing confusion and inconsistency. (Participant 10, 46-year-old female psychiatric nurse).

Another participant stated:

Our team worked tirelessly, adapting quickly to the changing guidelines and protocols while trying our best to provide quality care to every patient. (Participant 5, 37-year-old female psychiatric nurse).

The participants made a concerted effort to provide quality care to every patient, demonstrating their dedication and commitment to their profession. This statement reflects psychiatric nurses’ resilience and adaptability in the face of challenging circumstances, underscoring their unwavering determination to deliver the best possible care during crises.

• c)Fear of working in COVID-19 units and contracting the virus

Psychiatric nurses experienced intense fear while working in COVID-19 units. They were worried about contracting the unfamiliar virus and spreading it to their loved ones. This concern is reflected in the following quote from one of the participants:

For me, I was really worried not about what would happen to me but what would happen to my family members. (Participant 4, 49-year-old male psychiatric nurse).

Yes definitely, some nurses were uncomfortable with nursing patients that had tested positive for COVID-19. The fear of getting infected with the virus and infecting the very same patients and your loved ones was also stressful. (Participant 3, 31-year-old female psychiatric nurse).

The above direct quotations share the participants’ fear of infecting themselves and their families with the COVID-19 virus through working in the psychiatric hospital.

Theme 4: recommendations to manage future pandemics

Participants reflected on individuals’ experiences during the COVID-19 pandemic in psychiatric hospitals, offering valuable insights that can inform better management strategies for future pandemics in similar environments.

1. Mental health of staff and their involvement in decision-making

The participants emphasised that management should actively listen to staff and ensure they, along with others, have the necessary resources and support to stay safe. This highlights the importance of clear communication, understanding, and providing essential tools or measures to maintain a secure environment, particularly during crises like the COVID-19 pandemic, where safety protocols are critical. A psychiatric nurse elaborated on this point:

They should listen to us and make sure we have all the things we need to stay safe. (Participant 8, 50-year-old male psychiatric nurse).

Another participants shared:

It also highlighted the need for better mental health support for healthcare workers. Healthcare workers’ well-being should be a top priority, you know what they say about caring for the carer. With better mental health support and sufficient resources to manage stress during a pandemic, we might also function even better with no anxieties. (Participant 5, 37-year-old female psychiatric nurse).

The psychiatric nurse stressed the importance of giving staff support during the COVID-19 pandemic. The support included material and immaterial support.

• b)Clearer communication and information sharing

The study revealed that participants recognised the increased importance of effective communication and information sharing in their workplace amid the challenges COVID-19 posed. Psychiatric nurses noted that it became essential to explore improved communication and information exchanges within psychiatric settings and their influence on their work.

It’s also important for hospitals to have better communication and support systems in place for their staff. (Participant 10, 46-year-old female psychiatric nurse).

Another participant stated:

Communication with staff about changes in guidelines would be crucial. (Participant 8, 50-year-old male psychiatric nurse).

The importance of keeping staff well-informed and ensuring they are aware of any changes in protocols or guidelines relevant to their work. This proactive approach is crucial to maintaining a cohesive and well-prepared team, especially in the context of a psychiatric institution during a pandemic.

• c)Staff training

Psychiatric nurses also recommended continuous training in infection prevention and control. The following direct quotation supported this claim:

Ongoing in-service training for all personnel to emphasize compliance with infection prevention and control guidelines. (Participant 9, 31-year-old female psychiatric nurse).

Hospitals should be ready for emergencies like this. They need to train their staff better and have plans in place. (Participant 6, 49-year-old female psychiatric nurse).

The above direct quotations show that psychiatric nurses felt their institution was ill-prepared for the COVID-19 pandemic, and training to prepare them for such emergencies is needed.

• d)Provision of resources

Participants emphasised the importance of having a thorough plan to safeguard the safety and well-being of patients and staff in psychiatric institutions. They highlighted that resources are essential to guide staff on matters such as isolation and quarantine areas, PPE, training and education, staffing levels, medical supplies and equipment, communication and support services, facility cleaning and disinfection, emergency response plans, and collaboration with local health authorities.

I think increasing the availability of personal protective equipment (PPE)… Hospital and management need to ensure that there is an adequate supply of PPE and develop plans for quickly distributing PPE that is adequate with a variety of sizes during a pandemic (Participant 3, 31-year-old female psychiatric nurse).

Another participant shared:

It emphasised the importance of adequate PPE supplies, improved infection control protocols, and investing in healthcare infrastructure. (Participant 5, 37-year-old female psychiatric nurse).

These statements from the participants indicate the need to provide resources for psychiatric nurses during pandemics to provide nursing care to mental health care patients.

• e)Evidence-based research to guide practice

Participants recommended that strategies be developed for managing psychiatric crises while following infection control protocols. Ongoing professional and skill development would help staff to remain updated on emerging evidence and best practices. A psychiatric nurse expressed this perspective in the following quote:

Research and preparedness may also prepare us for future pandemics so that we do not only research and prepare during the pandemic (Participant 3, 31-year-old female psychiatric nurse).

Another participant stated:

First and foremost, we need to invest more in public health, research, early warning systems, and pandemic preparedness. (Participant 5, 37-year-old female psychiatric nurse).

The participants believed that research would be an investment for the health department to ensure that psychiatric nurses are prepared for future pandemics.

Discussion

This study found that participants working in a psychiatric hospital during COVID-19 faced significant challenges and stress due to the pandemic’s impact and the difficulty psychiatric patients had in understanding COVID-19 regulations. Key challenges included balancing patient safety with providing high-quality care. The psychiatric nurses were also concerned about getting infected while caring for patients in COVID-19 units. Furthermore, the hospital’s lack of preparation and the constantly changing COVID-19 guidelines, including resource shortages, made their jobs more difficult. Participants felt unsupported by management but grew increasingly resilient and helped each other as they took on the responsibility of care. They ultimately suggested various strategies to improve psychiatric hospitals’ ability to handle future pandemics.

Psychiatric nurses found their roles in a psychiatric hospital during the COVID-19 pandemic difficult, and their responsibilities felt overwhelming. This finding aligns with the report by O’Regan-Hyde et al. [28] who noted that nurses initially faced uncertainty and anxiety surrounding COVID-19, particularly regarding its transmission, symptoms, and the impact on healthcare services. The realisation that COVID-19 posed a genuine and significant threat added considerable pressure, affecting not only their personal lives and health but also how they interacted with patients. Participants in this study struggled with the ongoing need to enforce COVID-19 regulations with psychiatric patients. This experience mirrors that of Wall et al. [29] who determined that nurses faced fear and uncertainty as they encountered the virus first-hand and witnessed its effects on patients. In a short time, these frontline experiences led nurses to fully recognise the seriousness of the pandemic.

The difficulties associated with the shortage of PPE to prevent the spread of COVID-19 in psychiatric settings were another significant challenge for psychiatric nurses. In a study conducted by Iheduru-Anderson [30] that explored the lived experience of acute care nurses working with limited access to PPE during the COVID-19 pandemic, it was found that nurses went through an emotional roller coaster, they were afraid, disappointed and feeling betrayed by their managers, as well as physically exhausted. Their experiences highlight the physical and psychological burden of wearing PPE, which contributed to the already stressful work environment this population faced during the pandemic.

Psychiatric nurses mentioned challenges such as maintaining social distancing, concerns about contracting COVID-19, and disruptions to regular care while attending to vulnerable psychiatric patients. These findings align with a study conducted in Europe, which highlighted that the nature of working in mental health services, especially with mentally ill patients who are actively psychotic and out of touch with reality, made it difficult to follow social distancing and other COVID-19 guidelines [31]. Nurses had to balance the need to ensure patients’ physical health and safety with addressing their mental health needs. Their resilience and patience were crucial in supporting patients’ well-being during the pandemic. Similarly, a study conducted by Lyons and Brewer [32] found that the nature of some patients’ mental illnesses meant they struggled to understand the importance of wearing PPE and vaccinating for COVID-19, which created increased risks for infection control. This may explain the difficulties psychiatric nurses faced in enforcing COVID-19 infection prevention and control guidelines like social distancing in the psychiatric units [32].

The duty to care was another key factor emphasised by the participants in this study. Copel et al. [33] also found that nurses faced challenges in providing quality care due to sudden changes in their practices. Neiman [34] highlights that their participants stressed the importance of maintaining a therapeutic environment for both staff and patients during the COVID-19 pandemic. Evidence from this study shows that psychiatric nurses were tasked with balancing patients’ psychiatric needs while addressing their COVID-19 symptoms. Tavakol et al. [35] also identified several challenges nurses faced in ensuring patient safety during this crisis. These challenges included shortages of PPE, increased workloads, fatigue, changes in care delivery protocols, and limited resources, all of which added to the strain on healthcare providers.

The participants expressed concerns about how under-equipped and unprepared the psychiatric hospital was to handle the challenges linked to COVID-19. This finding is consistent with a study conducted in Saudi hospitals by Alreshidi et al. [36] which highlighted the critical need for psychiatric hospitals to be better prepared to respond to public health emergencies like the COVID-19 pandemic. The study further pointed out that perceptions of institutional preparedness varied, with some staff members feeling confident in their hospital’s readiness, while others expressed concerns about resource shortages [36].

This study found that unplanned and sudden changes in the hospital setting were both frustrating and stressful for the participants. This view aligns with findings from Copel et al.’s [33] study, which also reported that nurses faced frustration due to a lack of resources, such as PPE, and the challenges of providing care while ensuring their own safety. The rapid pace of change and the frequent updates to regulations during the pandemic caused confusion among staff, and the disruption of regular routines and ward programmes frustrated psychiatric patients and nurses. Similar findings were reported by Copel et al. [37] in the United States, where nurses experienced significant uncertainty and irritation during the early stages of the pandemic. Moreover, amid these challenges, participants in this study expressed a perceived lack of support from hospital management, citing issues such as PPE shortages, inadequate staffing levels, and limited access to training and support services. This view is supported by Ralph et al. [38] who reported that nursing staff in the United Kingdom felt hospital management’s communication and guidance were insufficient during the pandemic. The lack of support from management negatively impacted psychiatric nurses, as also noted by Digby et al. [39] who found that such deficiencies led to a decline in staff morale and well-being. Many nurses reported feeling stressed, overwhelmed, and unsupported, which affected their ability to provide effective patient care and maintain their own mental health [40].

A significant shortage of resources and supplies was ultimately observed in psychiatric hospitals during the pandemic, particularly with regard to PPE, such as masks, resulting in re-use practices among the participants. This finding is supported by a study Singh [41] conducted, which highlighted shortages of essential resources, including PPE, ventilators, and medications across many healthcare facilities during the pandemic.

These findings directly highlight a critical failure in health system preparedness and surge capacity. In South Africa, this inadequacy was not merely a lack of theoretical knowledge but a simple absence of practical, context-appropriate resources and training relevant to psychiatric hospitals. Reports of inadequate or inconsistent PPE supply in South African public hospitals were common, especially in the early stages, creating immense fear and risk for all nurses in general [58]. Many psychiatric hospitals in South Africa are old, overcrowded, and poorly ventilated, making isolation and physical distancing nearly impossible. This structural deficit made infection prevention and control protocols difficult to implement. When training did occur in psychiatric hospitals, it was likely rushed and generic, failing to address the specific challenges of managing COVID-19 in a psychiatric population such as patients who are disoriented, non-compliant with mask-wearing, or physically agitated.

The findings revealed that psychiatric nurses who tested positive for COVID-19 were unable to work, which caused feelings of uncertainty. Darvishpour et al. [42] identified similar major sources of stress among healthcare workers, including concerns about PPE shortages and proper usage, physical and emotional exhaustion, increased workloads, fear of infection, and limited experience in managing COVID-19. Participants reported feeling particularly vulnerable when PPE supplies were insufficient, a challenge noted by Drouard et al. [43] who found that the scarcity of PPE heightened nurses’ fear of contracting the virus. This fear, combined with the stress and anxiety of witnessing patients’ suffering, contributed to feelings of helplessness and emotional strain. Vázquez-Sánchez et al. [44] emphasised the importance of providing adequate support and targeted interventions to address the mental health needs of psychiatric nurses during the pandemic. Similarly, participants in this study stressed the need for better access to protective gear and stronger support systems to help avoid the stressful situations they encountered. Ultimately, the constant changes to COVID-19 protocols and policies added frustration and pressure to an already demanding work environment for nurses. Despite these challenges, participants demonstrated dedication and commitment to providing quality care to every patient.

Digby et al. [39] noted that psychiatric nurses in Australia faced significant mental and physical exhaustion due to the frequent need to adapt their practices to ever-changing protocols, leading to adaptation fatigue. This study also found an increased workload due to psychiatric nurses contracting COVID-19 and being forced to quarantine. A study conducted by Babamohamadi et al. [45] concurred on the difficulties healthcare providers faced during the COVID-19 pandemic, particularly focusing on nurses. Lucchini et al. [46] determined that nurses in psychiatric hospitals reported heavier workloads and increased stress due to the shortage of staff.

The increased workload also came from the added infection and prevention control duties such as constant cleaning, donning and doffing PPE, and screening. When colleagues contracted COVID-19 or were quarantined, the remaining, already insufficient workforce had to cover their shifts, leading to exhausting hours. Managing both psychiatric crises and potential medical emergencies related to COVID-19. [57] The psychiatric nurses not only suffered physical illness from COVID-19, but also severe mental health consequences like anxiety, depression, and PTSD [56]. In a country with a high rate of non-communicable diseases and a high burden of HIV among healthcare workers, the fear of severe illness was particularly acute [55]. In the South African context, this demonstrates the lack of a protective defence for the healthcare workforce. The system’s fragility meant that any external shock directly translated into increased individual burden and health deterioration for psychiatric nurses, who are a scarce and valuable resource. This has long-term implications for psychiatric nurse retention and the overall resilience of the health system.

Furthermore, participants built resilience by maintaining a positive mindset and adapting to the challenges COVID-19 created. They showcased resilience not only in their ability to manage the crisis but also in building strong bonds and mutual support among colleagues. Wu et al. [47] found that many nurses developed resilience during the pandemic by forming close connections with their peers, which helped them cope with the difficulties they encountered. This study’s findings further indicate the critical role of teamwork in navigating the challenges of the pandemic. Providing care for psychiatric patients requires a collaborative effort, with professionals from various disciplines working together to ensure comprehensive and effective care. This aligns with the study by Elsayed et al. [48] which found that nurses with higher resilience and stronger social support networks experienced better mental health and job performance. Participants shared that colleagues supported one another through regular informal meetings on a social media platform, which provided a space to discuss their feelings and concerns. These meetings fostered a sense of solidarity and served as an important coping mechanism during the pandemic.

Participants recommended strategies to improve hospitals’ preparedness, support the well-being of patients and healthcare providers, and optimise mental healthcare delivery during times of crisis. Participants emphasised the importance of open communication and promoting active participation, ensuring that all staff members have a voice in decision-making processes rather than being excluded from critical organisational decisions during a pandemic. They further stressed the need for essential tools and measures to create a safe and secure working environment, particularly in challenging situations like the COVID-19 pandemic. These findings align with a study by Buchberger et al. [49] which proposed strategies like promoting self-care practices, implementing organisational support systems like peer support programmes and access to mental health resources, and offering training and education on stress management and coping techniques. Together, these approaches aim to enhance the resilience and readiness among healthcare teams during public health emergencies.

The findings conclude with a strong emphasis on the need for strategies designed to enhance preparedness, improve access to mental health services, create a supportive and safe work environment, and ensure the availability of adequate PPE. Participants highlighted the need for the Department of Health to prioritise and equip healthcare workers, particularly psychiatric nurses, with essential resources, tools, and information to manage pandemics effectively. Temeng [50] also stressed the importance of clear communication between hospitals, patients, and their families, especially regarding the rationale behind isolation protocols. To support healthcare professionals in navigating the challenges of the pandemic, participants suggested integrating self-care strategies, stress management techniques, and coping mechanisms into training programmes. In support, Jurcik et al. [51] reported that mental health facilities had to rapidly adapt their in-service training to include education on new safety protocols and procedures introduced during the pandemic. Such measures aim to enhance institutional preparedness, protect the well-being of both staff and patients, and maintain the delivery of effective mental health care [52].

The experiences of psychiatric nurses of being overwhelmed, under-resourced, and inadequately protected were shared across many low and middle-income countries like India, Brazil, and other African countries. The core challenges of pre-existing weaknesses being exposed by the pandemic are a global narrative of low and middle-income countries [60, 61]. While nurses in high-income countries also reported burnout and PPE shortages, the scale and severity were different [59]. High-income countries generally had a greater capacity to surge, procure PPE, and implement technological solutions. South Africa, being an upper-middle-income country, had a baseline of scarcity, so the pandemic pushed the system into a deeper crisis, [60] whereas in many High-Income countries, it exposed cracks in an otherwise functional system.

Along with these challenges, the psychiatric nurses discussed the different strategies they employed to cope with the stresses of their jobs. The unique situation made their work more demanding and often difficult to manage. Despite some initial mixed feelings, all participants demonstrated strength and adapted to the crisis, showing a strong sense of duty and courage in their roles [12].

Strengths and limitations

This study had several strengths and limitations. One key strength was the use of in-depth interviews, which provided rich, detailed data about psychiatric nurses’ perceptions and experiences during the COVID-19 pandemic. Additionally, the transcripts of the individual interviews were returned to the participants for comments, corrections and approval. This member-checking strengthened the credibility of the findings, providing participants with an opportunity to clarify their intended meaning, thereby ensuring that their contributions were accurately represented.

The study also faced some limitations. The researcher is aware of social desirability bias, as familiarity with the participants and their personal experiences could influence data collection and interpretation. This familiarity may also impact the participants’ responses, affecting the generalizability and objectivity of the findings. The researcher kept a reflexive journal throughout the research process, where the researcher’s feelings were reflected upon. The researcher also ensured peer debriefing with the supervisors, which ensured that the researcher was grounded in the research process rather than the personal relationships. The researcher made a conscious effort to set aside her own preconceptions in order to minimise bias. The study was conducted after the pandemic’s peak, which allowed participants to reflect on their responses; however, this limited the capture of real-time experiences during the intense phase of the COVID-19 pandemic. The study also focused on a specific group in one context, and the findings may not be fully generalisable to psychiatric nurses in other parts of the world.

Conclusion

This study informs us that the South African health system, particularly its nursing workforce, was operating from a position of profound vulnerability when the COVID-19 pandemic hit. The findings are not just about a pandemic response but reflect chronic systemic issues, which include underfunding, staff shortages, and poor infrastructure that were tragically exposed. The path forward, as suggested by the psychiatric nurses themselves, lies not in a perfectly resourced system but in making strategic, pragmatic, and nurse-informed investments to build a more resilient system that can protect both its patients and its most valuable asset, the healthcare workers.

Abbreviations

COVID-19

Coronavirus disease 2019

PPE

Personal Protective Equipment

Author contributions

N.M conducted the research, analysed the data, wrote the original draft. N.N supervised the study, edited, reviewed, finalised and submitted the manuscript. A.T co-supervised the study, reviewed and edited the manuscript for final submission.

Funding

The study was partially funded by the University of Johannesburg Postgraduate Supervisor-linked Grant.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval and consent to participate

This study was considered the ethical principles outlined in the Revised Declaration of Helsinki (2024) [54]. The study was approved by the Faculty of Health Sciences Higher Degrees Committee. The Research and Ethics Committee at the University of Johannesburg approved the study. The ethics committee of the institution where the study was conducted also approved and granted written permission for the study. The study was also registered on the National Health Research Database (NHRD GP-number: GP_202208.099). Clinical Trial Number: not applicable. Approval was obtained from the Faculty of Health Sciences Higher Degrees Committee on 11 August 2022 (reference no: HDC-01-59-2022). The Research and Ethics Committee at the University of Johannesburg approved the study on 3 August 2022 and renewed the approval on 26 July 2023 (clearance number: REC-1647-2022; NHREC registration: REC 241112-035). The ethics committee of the institution where the study was conducted also approved and granted written permission for the study. Participation in this study was voluntary. Participants were informed about the study’s purpose, potential risks and possible benefits. Informed consent to participate in the study and permission to audio-record the interviews was obtained from participants before the interviews commenced. Personal information appearing on the consent forms, field notes as well as transcribed data was kept confidentially and kept in a locked cabinet at the researcher’s office while electronic information was stored on a password-protected computer. Only researcher will have access to data. All records will be deleted after five years. Data were anonymised prior to data analysis by allocating pseudonyms to participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.