In preparation, the trainer of the UFS team put together a book with the relevant training materials and supplements supplied by the MEGA project as well as an additionally sourced video on depression, a contextually appropriate article on depression conducted among Sesotho speaking respondents in the Mangaung Metro area, where the UFS team focuses their MEGA project activities. The Free State team further included a cultural competency test in the materials.

Despite meticulous planning and preparation, the UFS team faced some challenges. An unannounced taxi strike occurred on the day the training was scheduled for. As a result, several nurses working in the facility were absent, and the nurse who was earmarked to be trained could not be spared because the clinic was severely short-staffed. Only the social worker was released for the training.

The training commenced at 09:00. After an hour of training, the trainee informed the team that she is unable to stay much longer as she must attend to patients at a special clinic on a Wednesday (which was the training day). The team was not informed about this situation beforehand. The team requested the trainee to at least complete the Personal Reflection checkbox sheet and to go through the app questions and get her impressions on that and the training she was able to undergo. Completing the checkbox sheet took up 10 minutes and going through the evaluation took up 30 minutes.

The trainee expressed her gratitude for the training and the book with training materials and supplementary information on mental health and mental health care, and expressed that she would like to be part of the rest of the training, provided it is spread over two-hour sessions and several days – on days and times that suit all the trainees identified for the training.

It is clear from the pilot experience that it may prove challenging to recruit nurses for the eventual formal training, and to get their buy-in. Furthermore, the UFS MEGA team will have to customize the training per the needs of clinics. The team will have to work very hard to get buy-in from the Free State Department of Health, facility managers and the identified trainees for the training to take place successfully.

It should also be noted that mental health care is a lower priority part of the public health care system in the Free State, and presumably elsewhere in South Africa. In general,  mental healthcare receives less time, attention and resources in comparison to other health care programmes. For this reason, it may be difficult to recruit nurses for training.

A short evaluation of the training that did take place on the day was conducted. The trainee was asked to name mental health/illness topics she would like to see included in the eight-hour training course on mental health and mental health care. She indicated that she would like to see information on depression and stress and the differences between the two. These two concepts are contextually not often separated by the patients and some nurses. The same is true for PTSD and anxiety. It is important to include clear guidelines for nurses to distinguish between stress, depression, PTSD and anxiety.”

She also suggested information for nurses and social workers pertaining to referral to a psychiatric unit or a psychologist/ psychiatrist. Clear guidelines should be provided about when a patient can be treated in a clinic and when a patient should be referred for a higher level of care.

The trainee was also asked her opinion about the scheduling of the training. She indicated that a whole day is too long to take personnel out of their duty, as clinics are short-staffed. It will, therefore, be better to break up the training into two hours over several days.

For these reasons, the team at the University of Applied Sciences in Hamburg developed a train the trainer curriculum. The course covers mental health awareness, key facts about youth mental health and focuses specifically on helping nurses to identify signs and symptoms of depression in youth. The curriculum follows accepted adult professional learning principles and a blended learning approach.

During April and May 2019, we piloted the train the trainer curriculum with a class of German nursing sciences students at the HAW. The overall positive evaluation of the students and the trainers gave us constructive feedback for a further revision of the training. In July the revised material was piloted again by our colleagues at the University of the Free State in Bloemfontein in a local clinic and we received valuable feedback.