Background
Advocacy for human rights in mental health is essential to transform how society views mental health care users (MHCUs) and mental diseases. “Advocacy is empathy, compassion and community at work” [1]. Advocacy is described as a process undertaken by mental health professionals to change societal attitudes towards mental illness and remove the barriers that prevent MHCUs from achieving positive health outcomes in the community. It is a means of raising awareness of mental health issues in the community and contributing to legislation and service development [2]. Advocacy is thus a process to advance the rights of people with mental illness to reduce stigma and discrimination. In addition, it is a process of educating and informing communities and the families of MHCUs about mental illness, its causes, signs, symptoms and treatment [3].
According to the World Health Organisation (WHO) [2], mental health advocacy was initiated over 30 years ago by the families of MHCUs and later formed by the MHCUs themselves. This led to the emergence of mental health promotion movements in Britain and the United States [4]. Therefore, although stigma towards MHCUs has been acknowledged and persists, the emergence of laws like Moral Management Treatment in Europe and the United States transformed perspectives on the mistreatment of MHCUs [5].
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In the latter half of the 20th century, initiatives for the advancement of mental health emerged across Africa, notably in South Africa [6]. With the development of medication, stable MHCUs were moved from mental health institutions into the community, which helped destigmatise those who live with a mental illness. This strategy aims to influence a change in mental health laws and help MHCUs receive the services, accommodations, and medication they need.
While advocacy movements that help MHCUs and their families exist, psychiatric nurses also play an advocacy role. According to Funk, Minoletti, Drew, Taylor and Saraceno [7], psychiatric patients, their families, healthcare providers, and the community manage mental health advocacy movements. One of the WHO’s guiding principles and methods for addressing mental health is to support MHCUs through advocacy [8].
Families and society often mistreat MHCUs because they are ignorant of mental illnesses. In modern society, a connection with mental illness exposes a person to medicalisation and marginalisation [10]. In order to advance their human rights, it is necessary for psychiatric nurses to speak up for their patients. Advocating for human rights in mental health is one action against the stigmatisation and discrimination of psychiatric patients, which frequently forces them to live in solitude [6]. MHCUs see the world as a hostile place where they are not welcome. Advocacy for mental health thus helps MHCUs live their lives to their fullest potential and be accepted by society. Advocacy is also crucial for ensuring successful treatment outcomes for MHCUs [2]. MHCUs can ultimately receive the care they need and be treated humanely by engaging in mental health activism.
The historical and current incidence of human rights abuses in mental health care in various nations has been described as a global emergency and unresolved crisis, evidenced by reports of afflicted individuals’ physical and sexual abuse; discrimination and stigma; arbitrary detention; an inability to access medical, professional and housing resources; and denial of self-determination in financial and marital matters, among other deprivations [11]. An abuse of individuals’ human rights adds to the burden of those with already-existing mental health disorders [12]. Therefore, advocating for human rights in mental health is crucial in reducing this burden.
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In reducing the challenges related to advocating for mental health rights of the mentally ill, the WHO has put in place guidelines to assist in embracing the human rights based approach in mental health care [13, 14]. These documents are relevant for empowering psychiatric nurses as they emphasise that United Nations (UN) Member states to abandon legacy of coercion, overmedicalisation, discrimination and urge all stakeholders to prioritise development and replication of the rights based mental health services. The WHO’s goal is to transform mental health care globally by supporting independence, and social integration methods that value, empower, and include individuals who have mental illnesses. The aim is to develop and implement mental health legislation that upholds and defends the human rights of individuals with mental health conditions, including their dignity, autonomy, and social inclusion.
Increasing mental health issues have a major impact on South Africa, which is considered a low- and middle-income country [15]. Additional laws and regulations safeguarding MHCUs’ rights are thus in place in South Africa. The Mental Health Care Act No. 12 of 2002, specifies which rights of MHCUs required to be upheld by medical personnel [9]. Additionally, the Mental Health Review Board (MHRB) guards against psychiatric patients’ mistreatment by communities, families, and healthcare facilities [9]. Advocacy and human rights are also two focus areas for the National Mental Health Policy Framework and Strategic Plan 2013–2020 of South Africa (2013) [16]. The key advocates are nurses (particularly psychiatric nurses) who serve as primary healthcare providers, even though this paper promotes intersectoral collaboration in mental health advocacy. Additionally, according to Regulation 2598 of the South African Nursing Act No. 33 of 2005 [17], one of nurses’ duties is to “provide effective patient advocacy to enable the patient to acquire the health care he requires” [17]. Advocacy ultimately makes it possible for MHCUs to exercise their rights and access the medical attention they need. Psychiatric nurses are therefore required to maintain the advocacy role in MHCUs’ treatment.
All South Africans are covered by the National Health Act No. 61 of 2003; [16] the Act’s goal includes defending the rights of those with disabilities, such as MHCUs [18]. Accordingly, no mentally ill patient may be discriminated against. Nevertheless, MHCUs continue to face discrimination despite laws protecting their human rights. They frequently encounter problems that cannot be resolved, receive no support when facing layoffs due to their illness, are ineligible for housing, employment, or social security benefits, and face several other difficulties. Considering this, psychiatric nurses should promote the rights of this population.
The researcher (MEM) found that psychiatric nurses working in the PHC setting in South Africa encountered significant difficulties when promoting the human rights of MHCUs, despite advocacy for human rights being a component of mental health care. This was evidenced by MHCUs regularly returning to mental health services with the same unresolved challenges They experienced conflict with family members, an inability to obtain housing, medication, social disability grants, layoffs from work, difficulty accessing treatment and treatment facilities, and being excluded in decision-making. Therefore, it is encouraged that psychiatric nurses are empowered to enable them to advocate for MHCUs’ human rights. As a result of this phenomenon, it was recognised that a conceptual framework needed to be developed to make it easier for psychiatric nurses to advocate for the human rights of MHCUs.
Methods
Research aim
The aim of the study was to develop a conceptual framework to facilitate psychiatric nurses’ advocacy for MHCUs’ human rights in a PHC setting.
Study design
A postmodern constructivist paradigm was used in this study. A distinct perspective is provided by postmodern constructivism, which aims to give previously undervalued experiences more weight. Postmodern constructivism offers an open-ended approach to conceptualising aspects by adopting a different fundamental perspective of the world [19]. Three phases were followed: the empirical phase, the classification of concepts, and the development of a conceptual framework to facilitate psychiatric nurses’ advocacy for MHCUs human rights in a PHC setting. The researchers followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) to report on this qualitative study [20].
Setting
The setting for the study was mental health services in the PHC setting in the Sedibeng District of Gauteng Province in South Africa. The researcher (MEM) collected data in the participants natural setting, within a context in which they were comfortable to be interviewed [21].
Phase one: empirical phase
The empirical phase consisted of focus group interviews. This phase used a qualitative, exploratory, descriptive, and contextual design to learn about psychiatric nurses’ experiences advocating for MHCUs’ human rights in a PHC setting [22]. This section of the empirical phase is discussed as follows:
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Population and sample
Sixteen psychiatric nurses who met the requirements of the South African Nursing Council (SANC) under R425 of 1985 (as amended by R753 of 1988) [23], participated in three focus groups. A minimum of two years of experience working in PHC mental health services, registration as a registered psychiatric nurse with the SANC, constant interaction and caregiving for MHCUs, and a willingness to participate in the study were requirements for participation. Participants were chosen using purposive sampling. Two men and 14 women took part in the focus group interviews. The age range of the psychiatric nurses was 34 to 53. The years of experience in mental health nursing ranged from 3 to 26 years. The sample size was determined by data saturation [24]. None of the participants refused to participate in the study. Table 1 summarises the participants’ demographics.
Table 1
Participants’ demographics
Focus group number | Number of participant | Gender | Age | Years of experience in mental health nursing |
|---|---|---|---|---|
1 | 1 | M | 53 | 26 |
2 | M | 47 | 15 | |
3 | F | 43 | 3 | |
4 | F | 41 | 17 | |
5 | F | 43 | 10 | |
6 | F | 50 | 18 | |
2 | 1 | F | 43 | 17 |
2 | F | 40 | 11 | |
3 | F | 39 | 17 | |
4 | F | 40 | 17 | |
5 | F | 43 | 18 | |
3 | 1 | F | 44 | 5 |
2 | F | 50 | 10 | |
3 | F | 40 | 7 | |
4 | F | 45 | 4 | |
5 | F | 34 | 4 |
Data collection
Data was collected by the researcher, who held a Master’s Degree in Psychiatric Mental Health Nursing Science at the time of the study and had a wealth of expertise as an advanced mental health nurse. The researcher requested permission from the PHC setting’s mental health coordinator to seek permission from the psychiatric nurses to take part in the study. The researcher, with assistance from the mental health coordinator personally requested permission from psychiatric nurses to participate in the study. The psychiatric nurses were given an information letter which included the purpose of the study.
The researcher, the third author, used focus groups to gather data between January and June 2018. The participants in these focus groups gave their permission for the discussion to be audio recorded before the interviews began. The focus group interviews were conducted in a separate room within the PHC facility. Only the researcher and the participants were present during data collection. The set of open- ended questions used in this study was developed by the researcher for the interviews. One pilot focus group interview was also conducted to determine whether the research question (“How is it to advocate for mental health care users?”) was adequate.
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Three psychiatric nurses participated in this pilot focus group. According to the pilot interview results, participants could not articulate their experiences advocating for the human rights of MHCUs and were unsure of how to proceed. While 45 min to an hour is the recommended duration for interviews, the pilot focus group interview lasted less than 18 min [25]. Thus, it was evident that participants did not understand the research question. The study therefore did not include the pilot interview results.
In the focus groups that followed, the question “How is it for you to promote the human rights of mental health patients?” was posed. The participants talked about their experiences, including the difficulties and feelings they had when advocating for the human rights of people with mental illnesses. In contrast to the pilot focus group interview, the members in the group expressed themselves more freely and understood the question. Focus group interviews typically lasted 62 min. Field notes and observations were recorded during the focus group interviews to understand the intricacies and circumstances of psychiatric nurses’ behaviour in a natural situation and provide context for those behaviours [26]. No repeat interviews were conducted. The focus groups were all conducted in English. The researcher set aside any preconceived ideas and engaged in dialogue with each participant in order to explore their lived experience.
Data analysis
The audio recordings of the focus group interviews were immediately transcribed. The researcher analysed the focus group interviews using Braun and Clarke’s (2006) thematic analysis [27]. The data analysis process involved getting to know the data, creating preliminary codes, looking for themes, evaluating themes, enhancing and labelling themes, and creating a report. An independent coder with a PhD in nursing and expertise in qualitative research also examined the data, thereafter,
the researcher and the independent coder held a consensus discussion to confirm their agreement on the identified themes. Therefore, the themes were derived from the collected data.
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Measures of trustworthiness
The measures of trustworthiness were informed by Guba and Lincoln’s model in relation to credibility, transferability, dependability and confirmability [28]. Trustworthiness, which measures the degree of confidence qualitative researchers have in their findings, is used to measure trustworthiness of qualitative research [22]. The researcher interacted with the participants for six months and participants were consulted and provided feedback of the findings to ensure credibility. To promote transferability, an in-depth description of the methodology and participant demographics was provided. Raw data were coded, audited, and stored to guarantee dependability. An audit trail was further supplied. A thorough explanation of the study’s methodology was completed, and a step-by-step replication of the research approach was provided. To ensure confirmability, the researcher and independent coder verified the focus group interview results to ensure that the results could be independently verified.
Ethics
The study was approved by the following Approval Committees, namely: Research Ethics Committee (REC-01-61-2017) and Higher Degrees Committee at a university (HDC-01-40-2017), the Gauteng Department of Health (GP-201710-037), the Director of Sedibeng District Health Services, and the PHC setting’s mental health coordinator. The following ethical principles were adhered to throughout the research: autonomy, non-maleficence, beneficence, and justice [29]. Confidentiality and anonymity were also assured, and participation was voluntary. The participants were informed of the purpose of the study prior to signing the consent form.
Results
Phase one
Three themes were derived from the focus group interviews with the psychiatric nurses. It was determined that psychiatric nurses experienced advocacy as a constant strong push and an exhausting plea in their attempts to voice and protect MHCUs’ rights and needs. MHCUs were also unfairly excluded and discriminated against by various stakeholders. The psychiatric nurses also experienced a lack of awareness and training among stakeholders in mental health and recommended that awareness about mental health should be raised. The psychiatric nurses expressed that training should be conducted as a matter of urgency to destigmatise mental illness. Awareness was also required from the government to the societal level. Table 2 summarises the themes, sub-themes and direct quotations supporting the categories. The analysed data from the transcribed focus group interviews yielded the central concept as ‘the facilitation of empowerment’ of psychiatric nurses in advocating for MHCUs’ human rights [30].
Table 2
Themes, sub-themes, and direct quotations
Themes | Sub-themes | Direct quotations |
|---|---|---|
Theme 1: Psychiatric nurses experienced advocacy to be a strong push and an exhausting plea in their attempts to voice and protect the mentally ill patients’ rights and needs | • Psychiatric nurses experienced advocating for the human rights of mentally ill patients in different ways. • Psychiatric nurses experienced advocating to different disciplines, government, society and mentally ill patients’ family. • Psychiatric nurses experienced affective responses to their advocacy attempts. - Disempowerment - Frustration - Helplessness | • “One of the easiest way that I find is to write on the memo, unlike sending the patient on her own to the other side. If you have stated the symptoms well on the memo pad, it becomes easier for the people to help them.” (FG2, P3, F) • “I just find that because they are mentally ill, it is not a priority. I mean, you wouldn’t dream of doing that to a pregnant woman. Otherwise the government would be all over you. But if it is mentally ill patients, oh it is just fine.” (FG1, P3,F) • “So, most of us have good ideas, like taking the patients out during Easter. You can just take a kombi, take them to Rand Easter Show, to show that they are very important. They need social life also. But the government will say that they don’t have money for that. Our ideas are evaporating.” (FG1, P1, M) |
Theme 2: Psychiatric nurses experienced mentally ill patients were discriminated against and excluded by various stakeholder | • Psychiatric nurses experienced that mentally ill patients were excluded from: - Physical resources - Financial resources • Psychiatric nurses experienced that mentally ill patients were excluded from: - Human rights - Supportive services • Psychiatric nurses experienced that the exclusion of mental health services and mentally ill patients resulted in undesired outcomes | • “Some of our facilities are not even friendly. Look at that other mental health clinic. The environment is not conducive at all. There is little or no privacy. The place is noisy, lots of disturbance and on and on.” (FG2,P4, F) • “No one wants to come this side. It’s because they stigmatize and discriminate against mentally ill people. Now they are afraid that they will be stigmatized.”(FG3, P3, F) • “The other problem is medication. You know, sometimes we don’t have medication at the clinic. They will tell you that the medication is not available even from companies. Yet we are supposed to educate the patients about adherence. We complain when they default, but we don’t have medication on the other hand. You see, we contradict ourselves. You tell patients ‘drink your medications as prescribed’ otherwise you will relapse, but where is the medication?” (FG3, P3, F) |
Theme 3: Psychiatric nurses experienced that mental health awareness should be raised, and training needs to be conducted as a matter of urgency to destigmatise mental illness, from government to society level | • Psychiatric nurses experienced that awareness and training were required about mental health from government to society level - Government - Multidisciplinary team members - mentally ill patients’ families - Society • Psychiatric nurses experienced being fulfilled when they managed to render proper care to the mentally ill patients. | • “When you see a hippo, you only see the surface, and you don’t know how big it is underneath. So I think there’s there will still be more problems if we do not address you know, this. I think we agree to do this and we sign and we hand it to him, the judge that addressed the Life Esidimeni case. Because so far, I think he is one of the most influential people. If he can bring this to the light we would probably be one of the key priority areas as well.” (FG1, P3, F) • “Anyway besides all the problems, I sometimes feel happy and satisfied where I acted successfully to solve the patient’s problems it is like I won a trophy.” (FG1, P3, F) |
Phase two: Classification of concepts
The aim of this study was to develop a conceptual framework to facilitate psychiatric nurses’ advocacy for MHCUs’ human rights in a PHC setting. In developing a conceptual framework, the researcher had to classify concepts using Dickoff, James and Wiedenbach’s (1968) approach [31]. During concept classification, the findings of the empirical phase were used. The following classifications were adopted: The agent is the advanced psychiatric nurse, the recipients are the psychiatric nurses, the procedure is the facilitation of psychiatric nurses’ empowerment in advocating for the human rights of MHCUs, the dynamic or motivation is psychiatric nurses’ disempowerment in advocating for the human rights of MHCUs, the context is mental health services in PHC settings, and the outcome is empowered psychiatric nurses advocating for the human rights of MHCUs. Figure 1 illustrates the identified central concept.
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Phase three: Development of the conceptual framework to facilitate psychiatric nurses’ advocacy for MHCUs’ human rights in a PHC setting
After classifying concepts in phase two, a conceptual framework was mapped to facilitate psychiatric nurses’ advocacy for MHCUs’ human rights in a PHC setting. The conceptual framework is shown in pictorial form in Fig. 2.
Fig. 2
Conceptual framework to facilitate the empowerment of psychiatric nurses in advocating for MHCUs’ human rights.
Source: adapted from Makhale [30]
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Description of the conceptual framework
A large arrow is used to illustrate the conceptual framework. An arrow shows the direction in which something needs to be followed [32]. The relationship, working, and terminating phases are the three parts that make up the conceptual framework. The result of the facilitation process to empower psychiatric nurses in advocating for the human rights of MHCUs appears at the top of the arrow. To show how each of the phases relates to one another and how the facilitation process penetrates the arrow from bottom to top, the researcher employed broken permeable lines.
The researcher compared the phases of the conceptual framework to Maslow’s hierarchy of needs [33]. According to Maslow’s hierarchy [33], completing the bottom phase’s basic physical needs is necessary before going on to the following phase of the arrow. Thus, the relationship phase is completed before the working phase starts.
The arrow represents development. This has to do with how the advanced psychiatric nurse facilitates empowerment so that psychiatric nurses can become more adept at advocating for MHCUs’ human rights. Psychiatric nurses are equipped with knowledge enhancement, self-determination, and the ability to communicate and negotiate preserving the arrow’s symmetry [34]. In advocating for the human rights of MHCUs, psychiatric nurses experience self-actualisation and fulfilment as an outcome of the procedure, which produces empowered psychiatric nurses [35, 36]. They assume the duty of leading the charge in advocating for MHCUs’ human rights.
Several colours were used to describe the conceptual framework. The three phases of the facilitation process each feature a different colour: blue during the termination phase, orange during the working phase, and dark yellow during the relationship phase. The colours of disempowerment and empowerment have been combined and coordinated by psychiatric nurses to support the human rights of MHCUs during the facilitation process. The colour turquoise represents the outcome of the facilitation process. For the advanced psychiatric nurse, the researcher used yellow, and for disempowered psychiatric nurses, grey. The bottom of the arrow has a wider form. During the facilitation of psychiatric nurses’ empowerment in advocating for the human rights of MHCUs, the shape of the arrow becomes narrower, signalling psychiatric nurses’ participation and interaction in removing the burden of disempowerment.
Components of the conceptual framework
The components of the conceptual framework are discussed in more detail as the agent, recipients, context, dynamics, procedure and outcome.
Agent
The advanced psychiatric nurse is responsible for facilitating psychiatric nurses’ empowerment in advocating for MHCUs’ human rights. According to Empowered by Color (n.d.) [37], yellow is the colour of the mind and intellect, loyalty, and honesty, and it represents the advanced psychiatric nurse. When it comes to supporting psychiatric nurses in advocating for the human rights of MHCUs, the advanced psychiatric nurse is viewed as a thoughtful, devoted, and creative individual who is idealistic, upbeat, and emotionally resilient.
Recipients
In the facilitation process, the recipients are psychiatric nurses. Grey is a colour that represents disempowered psychiatric nurses [39]. It symbolises worn-out psychiatric nurses who are feeling exhausted from advocating for the human rights of MHCUs. It is encouraged that they are equipped with appropriate information and abilities to defend the MHCUs’ human rights. They engage with the advanced psychiatric nurse during the facilitation process and gain knowledge and abilities to support the human rights of MHCUs.
Context
The study’s context is mental health services provided in a PHC setting. The setting allows the advanced psychiatric nurse to socialise with other psychiatric nurses [40]. White, which symbolises purity and a successful beginning in enabling psychiatric nurses to advocate for MHCUs’ human rights, is the colour that best represents the context [41].
Dynamic
Dynamic/s refer to the motivations for actions [31] which is the source of energy driving the activity of facilitating psychiatric nurses empowerment in advocating for the human rights of MHCUs. The motivation behind efforts to support psychiatric nurses’ empowerment in advocating for MHCUs’ human rights is the dynamic. Psychiatric nurses felt disempowered to advocate for the human rights of MHCUs because of the lack of awareness among PHC professionals, the government, and the general society.
Procedure
The procedure describes the advanced psychiatric nurse’s actions to facilitate psychiatric nurses’ empowerment in advocating for the human rights of MHCUs. Facilitation is defined by Cranley, Cummings, Proffeto-McGrath, Toth and Estabrooks [42] as providing psychiatric nurses with assistance and advice as they learn how to deal with the difficulties they encounter when advocating for MHCUs’ human rights.
Establishing a positive environment and mobilising resources are the first steps in the dynamic, interactive facilitation process [43]. It fosters psychiatric nurses’ critical-thinking abilities. One of the study’s theoretical concepts is the facilitation procedure. In this article, facilitation refers to the process by which the advanced psychiatric nurse provides psychiatric nurses with the tools they need to advocate for MHCUs’ human rights. To facilitate change, psychiatric nurses should effectively and sustainably advocate for this population.
Building rapport between psychiatric nurses and the advanced psychiatric nurse is the goal of the facilitation process, which aims to equip psychiatric nurses with the skills to advocate for the human rights of MHCUs. In this instance, empowerment refers to giving psychiatric nurses the authority to firmly defend MHCUs’ human rights. Additionally, empowerment increases self-esteem by instilling a sense of self-belief. While providing comfort and support, the advanced psychiatric nurse assigns psychiatric nurses the advocacy duty.
The facilitation procedure is displayed using a colour scheme that transitions from a dark yellow throughout the relationship phase to a turquoise colour at the end of the process. The colour fusion that occurs through the phases’ permeable lines causes the colour shift. This represents advancements in the advanced psychiatric nurse’s ability to support psychiatric nurses’ empowerment as they transition from one phase to the next.
The advanced psychiatric nurse will empower psychiatric nurses with intra and interpersonal skills to use while advocating for MHCUs’ human rights. These include negotiating skills, self-awareness, social skills, motivation, and the desire to help others succeed. The facilitation procedure takes place over three interrelated phases of a conceptual framework, namely the relationship phase, the working phase, and the termination phase. These three phases are discussed next.
The relationship phase
To support psychiatric nurses’ empowerment in advocating for the human rights of MHCUs, it is essential that an advanced psychiatric nurse has a relationship with the psychiatric nurses. The goal of this phase is to establish rapport between psychiatric nurses and the advanced psychiatric nurse to foster a collaborative work environment.
The relationship phase forms the broader shape of the conceptual framework. Dark yellow, a colour that indicates a propensity toward depression, a lack of self-love, and low self-esteem, is used to convey this phase [51]. Psychiatric nurses feel demotivated and powerless to advocate for the human rights of MHCUs during this phase. The advanced psychiatric nurse will assist the psychiatric nurses in emerging from their dark yellow colour and becoming brighter by developing a relationship with them. The relationship phase thus comprises the subsequent actions:
Step 1: Building constructive relationships
The development of constructive relationships helps to reduce tension between psychiatric nurses and the advanced psychiatric nurse. During this phase, the advanced psychiatric nurse considers the fragility of the less empowered psychiatric nurses. The privacy and confidentiality of psychiatric nurses must be upheld during the facilitation process, and trust and moral principles underpin the partnership [54]. Mutual understanding and a reciprocal relationship are essential. Therapeutic communication is also employed to support psychiatric nurses’ empowerment, which has a restorative impact on these professionals. Thus, the advanced psychiatric nurse should reflect appropriate verbal and nonverbal communication skills [55].
Step 2: Contracting
The contract between the advanced psychiatric nurse and the psychiatric nurses is discussed. The purpose of contracting is to establish the facilitation process from the relationship phase to the termination phase [52].
Step 3: Assessment of challenges in the advocating role
The conceptual framework was developed based on the challenges discovered during the collection and analysis of data on psychiatric nurses’ experiences. These challenges led to the disempowerment of psychiatric nurses in their advocacy role for MHCUs’ human rights [30]. The advanced psychiatric nurse and psychiatric nurses are ready for the working phase after completing the relationship phase.
The working phase
During the working phase, the advanced psychiatric nurse informs psychiatric nurses about various activities that will equip them to advocate for the human rights of MHCUs. Since they have developed a rapport with the advanced psychiatric nurse, the psychiatric nurses are more at ease during this phase. The identified central concept and the conceptual framework serve as the foundation for the working phase’s activities (Fig. 2).
During the working process, orange was used, which is a colour associated with energy, control, practicality, and equilibrium. It stands for success, zeal, willpower, and inventiveness, and is a representation of tenacity and strength [37]. Psychiatric nurses recover their physical and emotional strength during the working phase and overcome their disempowerment. They adopt a more upbeat perspective of life and become committed to fostering social connections with stakeholders.
As highlighted by Dalrymple and Boylan [38], the advanced psychiatric nurse employs various dimensions that facilitate psychiatric nurses’ empowerment. During the working phase, psychiatric nurses are informed about the larger picture of mental health advocacy by discussing these dimensions with them. These dimensions encompass the activities listed by the WHO [2], which include promoting social change, problem-solving, empowerment, and emancipation.
Promoting social change
To encourage psychiatric nurses to advocate for societal change, an advanced psychiatric nurse provides support. The political environment, mental health systems, social norms and practices, the availability of resources, and, in particular, the shift from hospital-centred to community-centred treatment for mental health issues, as well as the social integration of mentally ill individuals in the community, are all factors that contribute to social change [50]. The following strategies can be used to impose societal change even in the face of resource constraints for mental health services: [56]
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Protesting: The purpose of protesting is to exert pressure on decision-makers to implement changes [57]. Given South Africa’s poor mental health status, peaceful protests on mental health issues may encourage governments to consider reforming their policies.
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Education: Mental health issues should be made known to society as well. Public stigma is unlikely to be supported by an educated or knowing society. When psychiatric symptoms first appear, a knowing community can quickly send the afflicted individual to mental health care services.
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Contact: Since mental illness is not contagious, it is important to encourage society to interact with those who suffer from it in the community. As more people become aware of mental health issues, the social distance between people decreases.
Promoting problem-solving
The second dimension is problem-solving. Psychiatric nurses will be empowered to use the principles and processes of problem-solving, as discussed by Muller [53]. Psychiatric nurses may also be empowered to use the problem-solving steps described by Hogan; [52] these steps relate to attitudinal change and the managerial and cognitive skills that psychiatric nurses will learn.
Empowerment and emancipation
This third dimension involves psychiatric nurses’ empowerment and liberation from disempowerment. Their empowerment and emancipation become possible by providing psychiatric nurses with activities that help the advanced psychiatric nurse facilitate their empowerment. The activities discussed below emphasise collaborative work between the stakeholders and psychiatric nurses, and changes in government policies.
Using resources to recruit MHCUs and families in destigmatising mental illness
According to the University of Johannesburg’s Theory for Health Promotion in Nursing [43], resources are any tool or strategy to support psychiatric nurses, MHCUs, and their families in destigmatising mental illness. The advanced psychiatric nurse uses the physical, mental, spiritual, and social resources found in their internal and external environments. These encompass expertise, material, physical, human, and time resources, knowledge, abilities, attributes, and competencies.
Recruiting MHCUs in destigmatising mental illness
The empowerment of psychiatric nurses in recruiting MHCUs is facilitated by the advanced psychiatric nurse. The South African National Mental Health Policy Framework and Strategic Action Plan 2013-202016 supports the recruitment of MHCUs; their participation in their care is crucial to promote optimal self-care [44]. MHCUs who possess knowledge are better able to defend themselves and educate the community by managing their situations through collaborative decision-making. They could eradicate stigma.
Recruiting families in destigmatising mental illness
Psychiatric nurses should provide families with mental health information since they play a crucial role in destigmatising mental illness. As a result, family members can destigmatise their challenged relative’s illness and handle their own psychological and emotional problems. To preserve the family’s strengths and eradicate flaws, psychiatric nurses are encouraged to evaluate families’ assets and liabilities [45].
Establishing support groups for family members
Mental illness affects family relationships; some families may experience rejection, resentment and unappreciative behaviour from their ill relative or the community, hence the need for family support [46]. Family members should be able to reach out when help is needed. Support groups are an effective intervention strategy for dealing with mental health problems [47].
Involving community non-governmental organisations (NGOs)
Using negotiation and teamwork abilities, the advanced psychiatric nurse empowers psychiatric nurses to engage community NGOs in MHCU advocacy [48]. NGOs are useful in raising awareness about mental health issues, providing mental health training, and supporting the human rights of MHCUs [7]. Numerous NGOs in South Africa can improve MHCUs’ outcomes by providing human rights services [49].
Facilitating vocal support in the community by helping someone in need
Psychiatric nurses have a duty to advocate on behalf of MHCUs by facilitating communities’ vocal support. Mayors, municipal council members, and traditional leaders need to all get involved in the community. It is also important to ask nearby establishments, such as churches and faith-based organisations, if they would be willing to speak out against the stigma associated with mental health issues. Speaking up helps spread knowledge, which ultimately reduces discrimination and stigma.
Facilitating community awareness of mental health issues
Deinstitutionalisation entails MHCUs being discharged and reintegrated back into the community. However, there has not been enough training to provide communities with information on mental health and mental illness, which is why stigma around mental health persists. By empowering psychiatric nurses to raise community understanding of mental health issues and dispel community fears, the advanced psychiatric nurse helps to empower their colleagues.
Facilitating community awareness of mental health is important in understanding MHCUs who are so chronically ill that their social skills, interpersonal relationships, and self-care skills are depleted, leading to behavioural changes. These individuals need support from the community. As a result, the community should be informed of the symptomatology of mental health conditions rather than labelling, because this is more descriptive and observable. Different methods can thus be employed to create community awareness, such as the use of media, awareness campaigns, recognition of special and commemorative days and mental health education for PHC professionals regarding mental illness so that MHCUs are appropriately diagnosed and treated holistically.
Termination phase
The relationship between the advanced psychiatric nurse and psychiatric nurses ends at the termination phase. This is indicated by a further narrowing of the arrow, which illustrates a reduction in psychiatric nurses’ disempowerment. The termination phase is not the end of advocacy; rather, it is an evaluation of psychiatric nurses’ empowerment in advocating for the human rights of MHCUs and saying goodbye.
During the termination phase, blue was used to stand for direction and order in life [50]. It is a colour that encourages both physical and emotional relaxation by pursuing serenity and calm. It is connected to stability and depth as well. Psychiatric nurses have overcome their various obstacles and are committed to being successful human rights advocates.
The colour blue, which represents new life, is found in the sky and the ocean [49]. Along with representing divinity, spirituality, and religious devotion, it also symbolises good communication, sensitivity to the needs of others, and the development of interpersonal skills among psychiatric nurses when working with stakeholders. During this stage, the psychiatric nurses have established a trustworthy rapport with the advanced psychiatric nurse and are comfortable and content with who they are. They feel at ease talking to the advanced psychiatric nurse about advocacy and mental health concerns.
The advanced psychiatric nurse and the psychiatric nurse evaluate the facilitation process. The advanced psychiatric nurse evaluates:
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Psychiatric nurses’ empowerment in using resources to recruit MHCUs and families to destigmatise mental illness.
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Psychiatric nurses’ empowerment in establishing support groups for family members.
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Psychiatric nurses’ empowerment in involving community NGOs in advocating for the human rights of MHCUs.
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Psychiatric nurses’ empowerment in facilitating vocal support in the community by helping someone in need.
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Psychiatric nurses’ empowerment in facilitating community awareness of mental health.
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Psychiatric nurses’ empowerment in providing mental health education and training to PHC professionals.
The termination phase also entails the advanced psychiatric nurse and the psychiatric nurses saying goodbye. Saying goodbye is termed the ‘adjourning phase’ by Hogan [52]. Psychiatric nurses should be informed when it is time to say goodbye so they may review the facilitation process and address any unresolved problems. The psychiatric nurses and the advanced psychiatric nurse will bid each other a heartfelt and kind farewell before parting ways.
The outcome
The outcome of this conceptual framework is empowered psychiatric nurses advocating for the human rights of MHCUs. The outcome of the facilitation process is coloured in turquoise. According to Understanding the Meaning of Colors in Psychology [51], turquoise represents communication abilities, organisational management development, and self-esteem. It indicates that psychiatric nurses are now in charge of advocating for the human rights of MHCUs and have received more authority and skills. In addition to being a healing colour, turquoise also denotes independence [37]. The disempowerment, frustrations, and powerlessness that accompanied psychiatric nurses while trying to educate ignorant stakeholders about the human rights of MHCUs have been resolved. The empowered psychiatric nurses have replenished the energy they lost from the weariness of pleading with stakeholders. They are more creative in their advocacy for the cause and have reclaimed emotional peace and balance.
Discussion
In this study, a conceptual framework to facilitate psychiatric nurses’ advocacy for MHCUs’ human rights in a PHC setting was developed. This role is important to ensure that MHCUs’ needs are addressed. This conceptual framework has the potential to support psychiatric nurses in the PHC setting advocating for MHCUs. Thus, the conceptual framework was developed based on the findings of psychiatric nurses’ experiences advocating for MHCUs’ human rights in a PHC setting.
The concept of mental health advocacy was created to reduce stigma and discrimination against people with mental illnesses and to advance their human rights [58]. The WHO [2] indicates the principal elements of advocacy entail raising awareness, providing information, education and training, mutual help, counselling, mediating, defending and denouncing the rights of mentally ill patients. The goals of advocacy are to lower obstacles, including the scarcity of mental health care, the stigma attached to mental illnesses, the infringement of patients’ rights, the lack of advancement opportunities, and the scarcity of housing and employment opportunities.
The American Hospital Association [59] has identified advocacy skills as one of the critical characteristics that nurses ought to possess. It has been proposed that nurses should engage in advocacy and teamwork in order to create healthcare reform [60]. Webster, Willey and Seldomridge [61] confirm that a fundamental set of abilities is needed to care for people with mental illness, namely: understanding of different mental disorders; therapeutic communication; working with a multidisciplinary team; and being an effective advocate for people with mental illness as individuals, families, groups, or populations.
Psychiatric nurses are encouraged to educate themselves on current social and political issues to advocate for causes that address injustice and prejudice. “The nurse advocates for equity and social justice in resource allocation, access to health care, and other social and economic services”, according to the International Council of Nurses’ Code of Ethics for Nurses [62]. It is the duty of the nursing profession to support underrepresented groups, such as mentally ill persons. In the clinical setting, psychiatric nurses are apt advocates for patients dealing with mental health issues since they are trained caregivers. Nurse advocates are also effective influencers, who can assist in solving key problems at the intersections of mental health and policy reform [63]. Empowerment of the psychiatric nurses would be evidenced when psychiatric nurses use resources to recruit MHCUs and families to destigmatize mental illness, establish support groups for family members, involve community NGOs in advocating for the human rights of MHCUs, and facilitate vocal support in the community by helping someone in need, promoting community awareness of mental health and providing mental health education and training to PHC professionals.
Limitations
Three focus group interviews were conducted, which may have reduced the potential total volume of data. There were also only two male participants in the pool of participants, which might be influenced by the fact that only a few males desire to be in the nursing profession in South Africa. The conceptual framework has also not been implemented in the PHC setting. This was an exploratory study; thus, further research is needed before implementation. The conceptual framework exclusively focuses on psychiatric nurses; other stakeholders’ perspectives were not included. It is important in the implementation of the strategies that all stakeholders in advocating for the human rights of MHCUs are involved. Furthermore, it recommended that all stakeholders, such as members of the multi-disciplinary team, should be part of future research to gain a more comprehensive understanding of the conceptual framework’s effectiveness and reflect a broader view of its application in various healthcare settings. Further quantitative research can contribute to present a clearer picture adding to this what was uncovered by this research.
Conclusion
This study aimed to develop a conceptual framework to facilitate psychiatric nurses’ advocacy for MHCUs’ human rights in a PHC setting. Advocacy is important and should be implemented from the governmental to the societal level and include all stakeholders. Psychiatric nurses play a key role in advocating for the human rights of MHCUs, and they should be empowered to fulfil this task. The conceptual framework is thus a unique contribution to the body of knowledge in mental health nursing. The outcome of the facilitation process will be empowered psychiatric nurses advocating for MHCUs’ human rights. It is recommended that future research is more comprehensive and collaborative by including other members of the multi-disciplinary team this will lead to effective mental health advocacy practices.
Acknowledgements
The authors would like to thank the participants for sharing their experiences and the psychiatric nurses in the PHC setting.
Declarations
Ethical approval and consent to participate
The study was approved by the Research Ethics Committee at the University of Johannesburg (REC-01-61-2017) and Higher Degrees Committee at the University of Johannesburg (HDC-01-40-2017), the Gauteng Department of Health (GP-201710-037), the Director of Sedibeng District Health Services, and the PHC setting’s mental health coordinator. Participation in this study was voluntary, and informed consent was obtained from participants before the interviews commenced.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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