Mental Health Conference Day 2

[00:00] Patients that have not missed risk.

[00:20] psychiatric practice and is the co-founder of Health Care Workers Care Network. Thank you.

[00:40] talk of the morning, so I thank you all for your attention. I think my talk is about healthcare workers and just going on from the last talk where the WHO is proposing those three circles. Two of those circles need healthcare workers.

[01:00] Let me explain what we're about. My name is Dr. Anjanet Merich. I'm a psychiatrist. I work primarily in the private sector. I also do training at the University of Atvartis runs where I'm upskilling the returning NMFC students in psychiatry. In March 2020,

[01:20] myself and a whole lot of other people formed a network which is called the Healthcare Workers Care Network and this was a primarily aimed at looking at the mental health of healthcare workers and we looked at it from various different angles. It was a collaborative

[01:40] group of people, including South African society of psychiatrists, SAMA, South African depression and anxiety group, a Methodist group, a psychology group and University of Victoria. I'm going to go a little bit into our main goals and then I'm going to move on to

[02:00] discussing the mental health of healthcare workers and we do have a track later where we're going to go where we will explain a little bit more about the work we do. So what are our main goals and these continue to change. One of the things is to promote mental health awareness amongst healthcare professionals and

[02:20] the general public, to provide education and training on occupational mental health concerns. Another track which we worked on very hard is to set up a confidential hotline and an online portal for healthcare workers throughout the country. Healthcare workers include anyone from the CEO

[02:40] hospital, all the way through to all the admin staff to the support staff. Anyone who works within a health facility we are considering healthcare workers and they can seek the media to the system and once these healthcare workers come through to the line they which is the the line is

[03:00] organized by our colleagues at SADAC. They are triaged. And if they need more assistance, what we do is we provide and we coordinate access to therapists who provide pro-bono counseling for these health care workers. We've got to volunteer a group of psychologists, psychiatrist counselors across the country.

[03:20] I'm very proud and under the stats last night, we provided over 860 hours of individual counselling since 2020. And one of the other big things around the healthcare workers network, which I think because I'm a psychiatrist, I'm very passionate about, is when healthcare workers reach out for help.

[03:40] And I'm going to speak about doctors because I am a doctor. By the time they've got to that point, they're in crisis. So, and the problem is, if you've ever tried to get an appointment with a specialist, it's impossible. So one of the aims was to expedite access to psychiatrists and to psychiatric admission, and that part of it.

[04:00] has worked very well. So I'm going to go back to our slogan which is caring for the carers by the carers and I'm going to go through each of these circles. I'm going to start with the orange circle which is the carers and those are our healthcare workers. Then I'm going to move onto the darker blue circle which is our

[04:20] health care providers, which many of us are in this room, and then I'm just going to end off with a few recommendations from our network. In terms of the mental health struggles of health care workers, and I could talk for hours on this specific slide, there was a large umbrella metanalysis, and

[04:40] I'm taking in mind what Mark said about statistics. But in terms of the depression and anxiety prevalence in healthcare workers, we were sitting at 1 in 4 presenting with depressive or anxiety symptoms. This was done in 2022. Other big issues in healthcare are...

[05:00] Our burnout is burnout. And the first two studies here, the first one was done on sub-Saharan nurses, was looking at a sample of over 2,000. They found that the burnout rate was over 50%. The second one was looking at South African and cosmological doctors, also pre-COVID, burnout rate.

[05:20] to 59 per cent and the last two were done post-curbit, South African rural doctors, 67 per cent and concerning although it was quite a small study, the last one was done on South African psychiatric registrars who are psychiatrists of the future at University of Adriatus runs and they found a 67 per cent

[05:40] burnout rates in 2022. These are the people providing the mental health care. Moral injury is a really huge mental health concern in health care workers and I'm going to spend a bit of time talking about this because I'm very passionate about it. What is moral injury?

[06:00] Injury is a term that we have taken from the military, you know, when people return from war and, you know, think about what they've done or what they've seen. And in health care workers, it is a psychological distress that occurs. It's a feeling inside that occurs due to compromised moral or ethical

[06:20] Why does it happen? It happens due to actions or inactions which contradict your personal beliefs, values or professional courage. It results in feelings of guilt, shame and self-doubt. And while moral injury is not a mental illness,

[06:40] It leads to the development of mental illnesses, including the ones I've mentioned. Dr. Neil Greenberg, if you're very interested in this topic, has got lots of research on this, and one of the big comments he makes is doctors say, nurses, healthcare workers, did I do the right thing? If anyone knows doctors or healthcare workers, we often quite a p-

[07:00] perfectionistic bunch and if we often ask ourselves did I do the right thing and did others do the right thing and did I witness others doing the right thing? And I think you can see where I'm going with this and through the COVID-19 pandemic. So as I said moral injury is not a mental illness.

[07:20] It is a feeling, it fits into the distress model in terms of the WHO, but it can contribute to its development. I really like this quote by Dr. Weyli Deane, who has done lots of work on this in the US. She says, moral injury occurs when health care providers

[07:40] are repeatedly expected in the course of providing care to make choices that transgress their long-standing, deeply held commitment to healing. Now when you have a look at this specific picture, and I chose it for a reason, when I looked at this picture it really speaks to my heart. It is a picture of

[08:00] nurse or a doctor, healthcare worker sitting on a chair being consulted by another healthcare worker with a bit of an alien suit and assuming during the COVID-19 pandemic. But these are the feelings of our healthcare workers who experienced this trauma.

[08:20] through the last couple of years. Why this is a specifically important topic to me is because I felt this moral injury myself. I was an intern in the early 2000s, and for those of you who know the healthcare system at that stage, there were no AIVs available.

[08:40] in the public sector. So here I am, a young intern, moving into Woodbank Hospital internal medicine my first few months of being a doctor and I'm surrounded by patients with CD4 counts of 34, 40 who are dying and I cannot do anything about it.

[09:00] walking into the ward every morning, and this is not an exaggeration, I'm sitting with 10, 20 files of death certificates which I have to sign off. I didn't know that was a moral injury. I thought that was just being a doctor, but that was trauma and if I am still feeling it, and I think

[09:20] can hear it in my voice 20 years later, what has happened to our healthcare workers, specifically our frontline healthcare workers, ICU trained nurses, etc., who've been looking after colleagues, who've been looking after, you know, family members, what has happened to them in terms of this moral injury? It is something we need to

[09:40] address. So I've spoken a little bit about the mental health challenges and I'm just going to just speak about some of the factors which impact the mental health of healthcare workers. One of the big things is societal pressure. I think maybe the general public

[10:00] But get that healthcare workers are humans as well. So yes, we work in healthcare facilities, but we return to homes, as many people have alluded, without electricity, without, you know, not a safe environment. And also, and this is specific, by bear of mind, in terms of healthcare workers being called heroes.

[10:20] Now, yes, healthcare workers need to be appreciated for what they do. But when you start elevating them to a hero narrative, it de-legitimises some of their concerns. Because how can you as a hero who needs to be strong and resilient then sit and complain about staff?

[10:40] about structure. There's a disconnect between that narrative. There's a stigma, there's a stigma in the general public but in health care workers there's a huge stigma in terms of seeking care, in terms of discussing it with employers, team leaders. In our public service, in our private sector.

[11:00] there's insufficient psychological support. Sorry. There is inadequate mental health support, leadership, organisational support, protecting our healthcare workers. Poor workplace conditions, and I'm going to go into this in the next slide.

[11:20] While I was doing this presentation, that top headline, which was doctors held at gunpoint, robbed during a board meeting at a Northwest hospital. That popped up onto a WhatsApp group I met and it was actually a statement from the MEC of the Northwest. This was a group of family members and doctors having their academic meeting last week, Wednesday.

[11:40] they were robbed at gun points. Another head man here, healthcare workers in the Eastern Cape calling on the Department of Health to prioritize safety of nurses and staff. This recent report in March 2023 on Rahima Musa by the Health Ombad, Hovnahoba. Rahima Musa and

[12:00] Child hospital is a filthy and neglected mess, says the health of a person. If you've read the report, it's a very compelling read. I looked at the report through the lens of a healthcare worker, how are healthcare workers managing in those situations, how are healthcare workers managing to even maintain any mental, mental

[12:20] illness in that situation. And here's where human muscle was, you know, bought out here, but this applies to many of our facilities. And then also while I was preparing this talk, a doctor who I follow on Twitter posted this tweet. So this is April 21, which is last week. It's a young female doctor.

[12:40] And I got permission to publish the tweets. And if you look at, if you understand how Twitter works, the bottom one was what she was responding to. So she was responding to the comments that COVID was a scam. And what she said is, we were carrying out body bags every hour, living in fear of going home because we would protect.

[13:00] potentially expose our families. Our parents were admitted and we lost family, people lost jobs and we had to explain to a 16 year old that both her parents have died. This was last week. The impact of the pandemic is still with our healthcare workers.

[13:20] care. I'm going to end off with just some discussion around us, the mental health care providers. I'm going to include myself in that. So, you know, we're talking about caring for the carers, but what about the carers of the carers? So the mental health of mental health care providers must not

[13:40] being elected. Individuals attracted to this field, many of us in this room, we are more susceptible to burnout because we are generally more empathic. So we take more on. There's massive problems in our mental health care system with staff availability, patients and mental health provider ratios.

[14:00] There's lots of research on psychiatric nurses and how they're strident. Retention issues exist both in the private and public sectors, and this is a global problem I know, but specifically in South Africa it's getting worse. And burnout is a significant issue among psychiatrists and all mental health care providers. I often joke with my colleagues that I

[14:20] I just moved from burnout to burnout, which is not particularly healthy. But this study showed that the burnout rate of over 5,000 psychiatrists was sitting between 30 and 50%. This was last year. So there are so many things that we could recommend and we will recommend, but I just wanted to.

[14:40] to just clarify a few.

[15:00] We can't stop talking about the soft and emotional stuff if we're sitting in a place which is not safe. Without the basics, we can't work. So basically what is needed is proactive leadership. You can actively work on these, improving these working conditions, which will improve staff morale, which will improve.

[15:20] mental health and I've seen this in certain you know different facilities where there is there are strong informed leaders. The other big thing which has come out in the research is don't underestimate if you're a leader yourself don't underestimate the importance of a thank you. Don't underestimate explaining to your health care workers thank you.

[15:40] Thank you for doing this.

[16:00] terms of for health care workers. Health care workers, their biggest concern is confidentiality. Biggest. That's why people don't come see me. I have to spend the first five minutes of a consult explaining how this will be a confidential session. We need to empower team leaders and managers to become confident in having these difficult conversations about

[16:20] mental health. People don't want to talk about mental health. It's very difficult and we need informed leadership from the top in order to decrease the stigma and improve access to mental health assistance for healthcare workers. And I'm going to leave you with this last slide which has a link, the QR code, links to our website.

[16:40] Please take a photo of the slide and share it with whoever you can. It's got our 24-hour helpline on and our SMS line. And I'm going to leave you with two points. One, I think I've emphasized that the mental health of our healthcare workers is incredibly important. But my second point is, we must not forget about the mental healthcare program.

[17:00] providers who are sitting in this room. We are a diminishing lot. We have, we are struggling with mental health issues ourselves and we need to appreciate and cultivate these mental health care providers. Thank you. APPLAUSE

[17:20] APPLAUSE

[17:40] brought us to the end of the session for this morning and I know we didn't give you much time to ask questions. We've got five minutes, we've gone over five minutes with the program and that cuts into your tea break. Are there any pressing questions that you want to flag to any of the speakers?

[18:00] We will take at least two questions if there are any. Otherwise we can close. Are you happy for me to close? Thank you. I want to thank all the speakers this morning. I think we've had a wide range of topics that talk

[18:20] about programs, tools and services available. But what really tugs at my heart is the World Mental Health Report and the gaps that they've identified. And then our last speaker tells us that even our health care workers are struggling under pressure.

[18:40] What really comes out is that the problems that we are sitting with in our system, in our healthcare system and our mental healthcare system is actually man-made. It's poor decision making, poor leadership and that's what brought us to the problems of our lives.

[19:00] that we are sitting with and prevents us from getting progress happening in our health care system and our mental health care system. So I want to beg, please, I know this much of our leadership is not here today. That's also an indication.

[19:20] When you don't show up, you don't care. We need to make a loud noise about the lack of services, the lack of leadership. I'm going to close. I'm going to close. Sorry.

[19:40] I was told there's no loitition. Can I finish? Well, thank you very much. Thank you.

[20:00] But I'm going to thank you. Thank you. At least you're showing up. Because when we speak, this is who this information is directed to. So, that's great. I heard you speak yesterday as well, telling us...

[20:20] money for mental health. I want the leadership to come forward and tell us how to access that money. Tell your people how to access money.

[20:40] give them the money so the work can get done. And that is how I would like to close this morning's session.

[21:00] We've only got one hand. Okay, thank you. And maybe you can see, while of course listening to our presentation, but also see this as an opportunity to reflect what is the role of security guards at your facility, at your workplace? What are their tasks and how is your relationship?

[21:20] to the security guards. How is the relationship between patients and security guards? Yes, at the beginning, I would like to tell you a story about something that happened at my clinic back in Germany. In 2019, there was an incident where

[21:40] patient with a mental disorder tried to escape the mental health care facility and the security guard caught him and restrained him. But in the process of being restrained, the patient got hurt so badly that he later died as a consequence of being restrained by the security guard.

[22:00] And this incident for the, I think it was for the first time, raised the question, okay, who is working as a security guard at our mental health care clinic? How are they trained? What do they know about mental health care? What do they know about mental health disorders?

[22:20] questions also arise not only in Germany but also in other countries, every now and then, mostly if an incident like this happens. And South Africa is one of the countries with the most security, private security guard companies and one of the countries with the most security guards employed.

[22:40] It's really hard to find exact numbers, especially how many security guards are working in mental health care or health care in general. But this was one reason why we did our small study. And when we looked into the literature and tried to find out, okay, what is known

[23:00] about the role of security guards in mental health care. It was kind of disappointing, but also really hard to get, to find research about this. What we know is that security guards play a significant role in mental health care facilities, and they are an integral part of psychiatrists.

[23:20] Of course, the main role is to ensure patients and staff safety. But there are a few studies reporting that they also perform other tasks, for example, monitoring the entrance of a ward, observing, but also restraining and secluding patients.

[23:40] or stepping in as informal interpreters without any qualification or training. So from the literature it becomes somehow clear that they work in mental health care facilities. They perform various tasks, sometimes tasks for which they are not.

[24:00] not properly trained. But what we also found is that there's not much research about the world. So they are often overlooked. Yeah, and this is why we thought it's needed that we do a qualitative study and ask about, okay, what are they doing in mental health?

[24:20] facilities. Thank you, Saskia. And like she said, we have sub-studies of this current study. We also have a systematic review where we're looking at the current literature today about acute disease and about their role in mental health care and about what they

[24:40] do. And so far we've found I think about 30 articles and this is worldwide. So this tells you about the scarcity of the literature that's out there about security guards, about is it because they're marginalized. I think that also it also falls part of that. So I'm just going to speak about the research, the analysis as well.

[25:00] So we did qualitative interviews with security guards and mental health care professionals where SUSCA was handling the mental health care professionals and I did it with the security guards transcending between ECZUL and COSA in Cape Town. So we chose a psychiatric hospital or a psychiatric institution in Cape Town where we

[25:20] conducted the study and this was between October last year and November 22 and then we analyzed thematically. And so it was 18 consisting of different security guards from different posts. We interviewed from the forensic and the acute ward which are extremely

[25:40] patients and less extreme patients. We also had acute safeguards from different posts such as the gates, the excess control and we for the mental health care professionals and it included psychologists, nurses, a number of them.

[26:00] And what we found, we tried to divide it into more formal tasks and more informal tasks. And formal roles and tasks were, of course, ensuring safety for staff and patients, escorting patients, for example, to family visits or doctor visits.

[26:20] serving and monitoring patients, access control, what you mentioned, security guards working at the gates, protocol adherence, support with restraining patients, and restricted forbidden items, for example, items or substances. And this might be not surprising. If I were to ask you what are the roles of security guards, what are their tasks, you would

[26:40] probably mentioned these kind of themes. More interestingly were the informables and tasks we found. For example security guards were used as interpreters. Without any knowledge of mental health disorders or any knowledge of what is an

[27:00] interpreter do how does an interpreter has to behave or act in a conversation they run errands for mental health care professionals as well as patients so mental health care professionals reported that it sometimes happens that they ask security guards hey can you please go to the grocery store and buy me and this and that

[27:20] They assist with medication and again without any knowledge about medication for mental health care patients. They were involved in patient care, for example assisting showers and also social interaction with patients, for example playing games, talking to them.

[27:40] reported that some patients ask security guards for advice, hey, what can I do with my depression?

[28:00] knows that the security guard is going to be in their environment and now the security guard knows something about them that maybe they don't want the security guard to know. So this also shows that it's not only challenging for the security guard for example to be used as an interpreter but also for the patient. Now there's

[28:20] and the security guns are around the patients the whole time. And now there's a person where they know, okay, I had a confidential conversation with my doctor, and there's a person not properly trained in mental health care, has maybe no knowledge about confidentiality, but knows a lot about my personal.

[28:40] personal things. And some of the informal roles as well included social interaction with patients for instance playing games in addition to self care or patient care some of the times they are asked to help with the shower

[29:00] of the patients and these are things that they are not even compensated for and I think these were one of their cries when they were saying these are things but to them it's seen as a form of assistance not really as a task so I don't think they informed enough that these are duties that these are tasks that they should be trained for and they should be compensated for as well.

[29:20] So there's an interesting code as well in relation to social interaction with patients where the participant said because these people, when a person has depression, they are always, they always have that thing, they always have what's bothering them. So as we are staying with them, we play with them, we do everything. So what they will constantly think about subsides. It's subsides. Others also

[29:40] sick advice, what can I do about this, what can I do about my depression? And then we advise them, we advise them from that, you can do this, this and that. And then also speaking to the mental health of security guards, we found a huge overlap between the themes because

[30:00] As you've seen with the quotes, it reflects hopelessness, it reflects frustration. So there was a lot of overlap with the themes. But we found that a lot of them are exhausted. Security gods are really exhausted in their duties. They have a strong dislike for their current job. And that relates to the fact that they were employed by a private company. I think by the time I was done with interviews, I was...

[30:20] I also hate the company because how can you treat people like these? And also frustration, a lot of them are frustrated. They're in constant worry, in constant trauma because they have this fear of using their jobs so they don't want to use their jobs because they know they can be easily replaced.

[30:40] Apparently their bosses tell them, I can just go get another one on the street like you right now. And therefore that brings up a lot of worry, especially because they work with mental health patients. And one of them also mentioned how they don't even receive counselling. They're not trained one. And secondly, they don't receive counselling. For people staying with mental, people with mental

[31:00] mental disorder, mental health and a psychiatric institutional care. I think it's very important that these people receive some sort of counselling, but that's what they also express, that they have this trauma, this heartlessness and they also really agitate it. I think one also echoed how when his home is now shouting at his kids, he doesn't have a proper approach to managing what is needed.

[31:20] he's dealing with in his head and that's one of the gaps that we found. So one interesting code is because what ties me is that you find yourself working but it's like you're also not working it's like you're volunteering you understand you see that your salary is coming in but it's discouraging maybe it's paid day-to-day but

[31:40] But you see the money later, or the other grievances that you have about money, and you see that they are delaying things, they don't attend to them. Other people end up giving up. Like now, we are going to leave, but they've cancelled our leaves. So are we going to work with, so how are we going to work with the retirement, of which that is not permitted?

[32:00] going to be here and we're going to be sleepy in the places that we live in. And then another one was that I think this related to the helplessness of the secretive God because he said, I mean sister what is happening is we don't have the right to speak directly to the hospital about

[32:20] our problems where the hospital can make things right for us and try to look into other problems. We don't have a right like that. The only thing that happens when we are here, we get an induction, they tell you how to work here and you cannot complain. Complain about how you're treated, the way that you're treating each other with the boss to the client. That is not acceptable

[32:40] and yet towards the security it is. And that leads also to the healthlessness that I've spoken, and I think also just to the frustration. The fact that the entire ethnic exhaustion as well, as part of the implication of their mental health due to working with psychiatry patients, they're also called for government intervention, for government to.

[33:00] not privatize security guards anymore, not give contracts to private companies, but to bring it back to them and absorb them. And maybe just to add, it was reported a very difficult situation, so the fear of laws because they are so easily replaced or easily took place.

[33:20] So that it sometimes was a case that security guards, they didn't want to get involved in a situation where the patient was aggressive because of the fear that they are doing something wrong and that they will lose their job. So the actual task, ensuring safety for patient and staff, and the fear of loss, it was sometimes, yeah, they were.

[33:40] like in the middle and were not able to perform their actual task, ensuring safety because of their fear that they would lose their job. Yeah, and maybe another theme that was very interesting was about power dynamics and the relationships.

[34:00] that there are blurred boundaries between patients and security guards and I think this includes a few aspects we already mentioned. So security guards playing games with the patients, talking to them, were asked for advice and one reason for this was that security guards and patients often share the same language so they were able to talk and

[34:20] their native language. And also they shared the same community. We worked on one cycle because the patients feel more confident talking to security guards about their community. But it also was associated with a fear of stigma. So there's a person that

[34:40] knows a lot about me, knows about my mental health disorder, and he or she comes from the same community. So patients are afraid that the security guard would go to their community and talk about them, talk about why they are in the psychiatry. Security guards are also perceived as threats by patients.

[35:00] So sometimes it was reported that when a security guard was involved in a situation with an aggressive patient, it doesn't lead to de-escalation, but makes the patients even more aggressive. Security guards are also perceived as scapegoats by patients and were easily blamed by mental health care professionals.

[35:20] And I remember one, we are moving to the map. Let's wrap up this one. Maybe that one mental health care professional mentioned that there was an incident where drugs were smuggled in the mental health care facility. And automatically the security...

[35:40] was planned because he was the person with the lowest education with a low salary. So without having evidence, they blamed the security. But on the other hand, and this is from my perspective a very important point, they were also perceived as a valuable source of information.

[36:00] health care professionals ask security guards, hey, you are always around that patient, can you tell me how is he mentally stable, is he aggressive? So on the one hand, they are very valued to get information about the patient, but on the other hand, easily blamed, excluded, not perceived as a threat.

[36:20] part of the team because of lack of professionalism, low educational status. And I will skip this and maybe the technical session.

[36:40] care professionals. And as much as we're doing that, we need to prioritize mental health care for everyone who else who works with people with mental problems, mental psychological distress as well, including security guards, especially those in psychiatry care. So we want you to go and ask when you go back to your place, ask who works as a security guard? What asks?

[37:00] are performed by security guards, what consequences could this have for the security guard and the patient and yourself? We thank you. Thank you very much.

[37:20] that involves psychiatric patients. You know, things like de-escalation, and when they come into the world at times, you had to breathe them about the patient's condition. And it was very, very difficult because you would have patients who have cardiac problems, a patient who asked might be prone to epilepsy, but it had to be received.

[37:40] So you had to breathe them to make it. So in that way, you were kind of breaking patients' expectations. So the security guard, they had no choice. They were actually forced by institutional laws to actually do that, to be part of that.

[38:00] of actually to participate in restraining, you know, many time here, you know, a psychiatric patient who is vying. So what can they do to actually tackle, you know, issues like that where they actually feel like they are forced to do that. You don't want to do it, but they haven't got any choice. They are employed by these institutions.

[38:20] Thank you very much.

[38:40] They need to be trained. They shouldn't skip it. They shouldn't run away from it. It's important for them to be trained so that they can work adequately with the patients with mental well-being, especially if they work in a health care setting or psychiatric institution that we're doing. And I think also your other part of the question related to, what can they do if they don't want to?

[39:00] party in that. I think that's what they also raised, the fact that they are no appropriate channels. Who they can only report to was their boss, nobody else. They can't go to the hospital, they're not allowed at all to speak to anybody else outside of that and that is the very same person that says I can fly you now. And maybe to add to that.

[39:20] I think it's important that security guards also perceive themselves as some sort of profession when they work in a mental health care facility. And every professional has some sort of training. Also, this would be maybe an argument how you convince security guards to get trained.

[39:40] They did You're not two questions for the sake of time you might not be able to you know exhaust Just appreciate the presentation I never imagined coming to this conference that I would say presentation like this that talks to

[40:00] You know, the role of security guards, they're very insightful. In the other side, did you find that in some institutions, did you find that there is some, you know, level of engagement between health professionals, you know, with security guards?

[40:20] on these issues, maybe not even talk about formal training, but just, you know, human-to-human engagement does. Did you find that that happens or not at all?

[40:40] Just... Yeah.