TABLE 3.

Emergent themes from focus groups.

Themes	Subthemes	Illustrative quotes
Knowledge of physiotherapists acquired since graduation about mental health	Prevalence of mental illness and stigma Participants expressed concerns about the prevalence of mental illness. They have noted treating more PLWMI than in previous years. They also stated that they are also guilty of stigmatising PLWMI because they have had no exposure of treating PLWMI at the undergraduate level; they rely on their own perceptions and negative stereotypes.	‘The training is required more now than in previous years because of the demands on social life and the threats to society, and stressors placed on life are on the increase. There should be a greater awareness amongst physiotherapists about mental health’. (Participant 4, focus group 2)
		‘No exposure at the undergraduate level will lead to negative perceptions and fear of PLWMI. Mental illness has always been there, but we shy away from conditions we don’t understand’. (Participant 5, focus group 3)
		‘When the referral comes from the psychiatric ward for physiotherapy, there is no one that will volunteer to go, as we are afraid of past experiences of other physiotherapists reporting aggressive patients. We don’t know what to expect from the patients and we fear for our safety and the safety of the patient’. (Participant 1, focus group 1)
		‘I don’t want to work in a psychiatric hospital because I am scared, all the patients will be aggressive like I see on TV’. (Participant 4, focus group 1)
	Self-learning Participants stated that because of the lack of knowledge at the undergraduate level about mental health, their knowledge gained has been from working with PLWMI over the years, and this was a disadvantage to that patient group. The knowledge that they have gained over the years has been self-taught, and working with other members of the multi-disciplinary team that have knowledge about mental health.	‘The knowledge that I have gained is a working knowledge that has been gained through years of working, I have been using a trial-and-error approach because I lack the proper education about mental health’. (Participant 4, focus group 3)
		‘I have attended in-service training about mental health from other disciplines at my institution’. (Participant 6, focus group 3)
	The role of physiotherapy in mental health Some participants were surprised that after graduation they had a role to play in mental health. Participants mentioned that after graduation they solely believed that their role was purely a physical one, and they were only going to see conditions that they were taught at the undergraduate level. Participants were not aware that physiotherapy treatment modalities can be used to treat PLWMI.	‘I had no idea that I had to treat PLWMI after graduation; I didn’t know what my role was as a physiotherapist. I attended a conference and I heard a physiotherapist talking about mental health and I was utterly surprised’. (Participant 1, focus group 3)
		‘Not sure how I can treat a patient just with a mental illness’. (Participant 4, focus group 2)
Knowledge that physiotherapists wish they had acquired before graduation about mental health	Effects of mental health on physical health Participants stated that they were not aware that mental illness can affect a patient’s physical health. They solely believed that they were only responsible for managing the physical illness of a patient. To understand how mental illness affects physical health, education is required about signs and symptoms and aetiology about mental health as well and the medication and its side effects.	‘It is difficult to treat a patient with a co-morbid mental illness when we don’t understand the effects of the medication as it affects the rehabilitation of the patients and that leads to us assuming the patient is being difficult or lazy’. (Participant 1, focus group 1 )
		‘I wish we had learnt about the different mental illnesses as well as how they affect the physical health of a patient, then I would be able to manage patients’. (Participant 3, focus group 1)
	Communication strategies Participants stated that they lacked proper communication strategies when managing PLWMI and thus making treatment sessions far longer. They expressed their frustrations for not being able to do their job because they were unable to fully relay instructions to PLWMI. The consensus was if they had received the relevant theoretical knowledge followed with the practical exposure at the undergraduate level, they would be able to better manage PLWMI.	‘I should have been equipped with communication strategies at undergraduate training, as it is not easy to manage a patient with dementia; sometimes they don’t understand simple instructions and then it becomes difficult to do your job’. (Participant 4, focus group 2)
		‘I would like to know how to manage a patient with depression or anxiety that has been attributed from the physical condition, like a patient with paraplegia experiencing depression’. (Participant 2, focus group 2)
		‘If a patient tells me they want to kill themselves, I don’t know what to do, I need to have some skills on counselling’. (Participant 5, focus group 1)
	Referral processes Participants would have liked to know how the referral process works and what the roles of the other members of the multi-disciplinary team are. They expressed their concerns about not being confident in referring PLWMI to other disciplines.	‘I don’t know how to refer a patient who is undiagnosed with a mental illness. I don’t know when to refer to a psychologist or psychiatrist’. (Participant 4, focus group 1)
		‘I’m not sure if a patient who is undiagnosed requires a social worker or occupational therapist and if those professions manage those patients’. (Participant 6, focus group 2)

PLWMI, people living with a mental illness.