The journey between ideal and real: Experiences of beginners psychiatric nurses.

BACKGROUND: Understanding how novice nurses perceive their career in the psychiatric ward can be helpful for nurse educators and managers to gain insight into psychiatric nursing care and adding applicable knowledge to the development of support strategies for this group. The aim of this study was to describe and illuminate experiences of new graduated nurses working at a psychiatric ward in an Iranian context.
MATERIALS AND METHODS: A descriptive phenomenology has been chosen. Participants with baccalaureate degrees in nursing were selected purposefully and they all had less than 6 months of work experience in psychiatric wards beforehand. The study was conducted at the Razi Hospital in Iran. Data were collected through unstructured individual in-depth interviews and analyzed according to the Colaizzi method by means of Husserlian phenomenology.
RESULTS: Three main themes were found in this study, of which six sub-themes were constructed as follows: Being in the world of fear and complaint, which has been abstracted by having mixed feelings of conflict and compliant on entry to the psychiatric ward, doubt about adequacy of being a psychiatric nurse and working in psychiatric ward and a frightening and non-supportive environment; A sense of imprisoned and confined, which has been constructed by different experience with different environmental milieu in psychiatric ward, as a lock sense; Becoming a psychiatric nurse, which has been constructed as a sense of usefulness, a sense of sympathy and compassion for patients and a sense of professional identity.
CONCLUSIONS: This study identified areas that require modification by providing insight into lived experiences of beginners' nurses as the value in psychiatric ward. New graduated nurses may face negative perceptions and feelings due to confrontation with a new environment, patients and colleagues as well as shortcomings in the preparation.

INTRODUCTION

Mental health problems and deviant behavior have traditionally not been accepted by the society.[12] Providing nursing care for people who are suffering from psychiatric disorders is emotionally demanding and burnout is often the consequence of long continued exposure to this stressful working situation.[3] Stress and burnout associated with psychiatric nurses have several major sources regarding providing nursing care at psychiatric ward that are assumed to be inherent in the nurses’ role.[45] Workload, collaboration with other professionals, confidence and competence in the nursing role and lack of support are examples of areas that have been highlighted as major sources of stress for psychiatric nurses.[678] This is especially true for novice nurses, who are starting their work at the psychiatric ward.

Understanding how novice nurses perceive their career in the psychiatric ward can be helpful for nurse educators and managers to gain insight into psychiatric nursing care and adding applicable knowledge to the development of support strategies for this group. In Iran, after 4 years of formal nursing education, they become graduated nurses and as general nurses start their job at a nursing ward.[91011] Therefore, novice nurses may have little or no experience of the situation of which they are expected to perform.[911] This different situation for all nursing staff, especially newcomers, is unique and therefore its essence should be discussed and understood in more detail.[12]

Studies conducted outside Iran showed that many aspects of the work in psychiatric wards can be stressful.[1314] This work situation has often been viewed differently; as less attractive and less visible by other nurses;[15] a manner of suffering from physical or mental health problems associated with work-related stress;[16] feeling as being confined in a prison-like world;[17] professional and ethical tensions in the process of keeping patients safe while trying to promote recovery;[12] feelings of fear and inadequacy as well as a lack of understanding among well-experienced nurses;[18] learning through tears and feeling frustrated[19] or burnout and dissatisfaction with the workplace during the first 15-month period for nurses;[7] higher levels of depersonalization; and burnout in graduated nurse's experience.[14] In all above aspects, types of settings and level of healthcare provider and experiences can be affected by stress in different manner.

Stress and burnout associated with psychiatric nurses’ work has been described and studies have primarily been based on a quantitative method.[45] These studies show several major sources of stress when providing nursing care at psychiatric wards. Workload, collaboration with other professionals, confidence and competence in the nursing role and lack of support are examples of areas that have been highlighted as major sources of stress for psychiatric nurses.[20] The above studies were conducted regarding problems of working in psychiatric ward with a focus on stress and burnout. To the best of knowledge, no studies were found to explore lived experiences of new graduated nurses who work in the psychiatric ward in Iran. Therefore, the aim of this study was to describe and to illuminate new graduated nurses’ experiences of working at a psychiatric ward in an Iranian context.

MATERIALS AND METHODS

The Husserlian phenomenology has been chosen[21] because of its descriptive nature and its aims to identify the structure of experiences as described by research participants. Phenomenology is an inductive research approach with focus on human phenomena,[22] which is suitable for study of lived experiences and to describe key factors that are common across beginner nurses in the psychiatric ward.

Study setting and participants

Participants were selected purposefully from Razi comprehensive psychiatric hospital, the biggest psychiatric hospital in the Middle East with 1375 beds. The study participants have baccalaureate degrees in nursing and had less than 6 months work experience in psychiatric wards beforehand, ranged from 20 days to 6 months (mean = 3.5). All study participants worked at the acute psychiatric ward due to a rule at the hospital that all beginners have to start their career from the acute ward (six males and eight females). Participants were determined based on their experiences as well as criterion of saturation, which means when themes identified during the ongoing data analysis are repeated and no new themes emerge.

Data collection

Data were collected through unstructured individual in-depth interviews in 2011. Interviews continued until no new data, themes or essence emerged from the participants.[23] The venue of the interviews was selected by the participants and all interviews took place in the psychiatric ward in a consultation room. Interviews were digitally taped, transcribed verbatim and lasted around 1 h. The interviews started with general questions such as: Please tell me about your experiences of working in a psychiatric ward as a new graduated nurse. The following questions focused on expectations and work-related situations in the psychiatric ward.

Data analysis

Data analysis was made according to the analysis method of Colaizzi (1978) to provide a rich description of the phenomenon under study. The Colaizzi method was chosen to explore the meaning and essence of the experience of being beginners to a psychiatric ward.[24] The analysis included seven procedural steps recommended by Coliazzi. Each nurse's interview was transcribed verbatim and all thoughts, feelings and ideas were written to assist with the bracketing and reflective process.

Significant phrases and statements relating to the research questions were highlighted and extracted from each interview. Overall, 225 significant statements were extracted and this process has been checked through a panel of experts with the research team. Meanings were formulated from every significant statement and then organized into clusters of themes. Six theme clusters to describe the experience of study participants and three themes were identified and were common to all descriptions of work in the psychiatric ward as a new comer. The themes were used to provide a description of the experiences. To describe the phenomenon in more in-depth, theme clusters and formulated meanings were incorporated into the description to create its overall structure and to ensure that it contained all of the elements of the experience.

The exhaustive description reduced to an essential structure of the phenomenon. The researcher tried to provide a description of the process and meaning derived through the previous steps of analysis. The exhaustive description was returned to the individual nurses for confirmation of validity. All the participants noted that they recognized this description with their experiences with regard to work in the psychiatric ward as a beginner. Finally, the researcher wrote a rich and exhaustive description of the new graduated nurses’ experiences from working in the psychiatric ward.

Ethical consideration

Ethical approval was obtained from the University of Social Welfare and Rehabilitation Science and informed consent was obtained prior to each interview. The participants were given the opportunity to decline or leave the research process at anytime. All transcripts, notes, audiotapes, peer debriefing notes and journals were kept in a secure place for audit trial.

Trustworthiness

To ensure pure description of data, researchers used bracketing.[23] Before data were collected and analyzed, the researcher set aside his potential prejudices and biases. A copy of transcription of the interviews, along with a summary of the researchers’ perceptions of the interviews, was sent to the participants. Participants were asked to validate the dialogue and make additions or subtractions if they found changes necessary, but nothing was changed by the participants. Meanwhile, a sample of the interview text was analyzed by an independent qualitative researcher to validate the themes identified. This strategy showed no big differences between two independent analyses. Moreover, for validation, the whole process of analysis was checked with the research team as a panel of experts. Finally, a triangulation of researchers helped to take into account different perspectives when analyzing the data.

RESULTS

As a result of this study, the meaning structure of the experience of work in a psychiatric ward as a beginner was formulated in three main themes, which were constructed to six sub-themes: (1) Being in the world of fear and complaint that has been abstracted by having mixed feelings of conflict and compliant on entry to the psychiatric ward, doubt about adequacy of being a psychiatric nurse and working in a psychiatric ward and a frightening and non-supportive environment; (2) a sense of imprisoned and confined, which has arisen by different experiences with different environmental milieu in the psychiatric ward, a lock sense; (3) becoming a psychiatric nurse: A sense of usefulness, which has been abstracted by; a sense of usefulness, a sense of sympathy and compassion for patients and a sense of professional identity and a sense of professional identity [Table 1].

Table 1

Illustrating the emergent themes, theme clusters and some formulated meaning from lived experience of being a beginner to the psychiatric ward

Moreover, the meaning structures of the beginner nurses’ experience of work in the psychiatric ward is presented in Figure 1.

Figure 1

The journey between ideal and real: The meaning structures of the experience of work in the psychiatric ward as a beginner

Being in the world of fear and complaint

Having a mixed feeling of conflict and compliant on entry to the psychiatric ward.

Study participants explained that their first impression at work in a psychiatric ward was like a nightmare; particularly, they suffered from anxiety during the beginning weeks of their works. They experienced a lot of conflicts and complaints regarding work at the psychiatric ward, such as complaint of orientation, complaint and arguments with personnel, compliant with work pressure, chaos, insufficient staff and resources and compliant with nurse-patient relationships. They explained that they did not get good orientation, but because of lack of time and shortage of personnel they had to start their job as a nurse immediately.

“When I was introduced to the head nurse as a new staff, one of the nursing staff explained the routines, some basic rules and different places of the ward in a few minutes and after that I had to start my work soon... I found myself in the ward as a nurse without good orientation”.

Participants believe that due to intense pressure at work, staff members did not have enough and good communication with the patients. They are frustrated with the time-consuming activities like documentation and reports. Even nursing staff do not share their ideas or thoughts with their colleagues as they do not have time. They usually rush patients to follow their orders and are very busy. Connections occur mainly within group of nurses.

“Patients need to talk, they have a lot of questions like when will I be discharged? When my family will come? Can I go out for a while? A lot of similar questions and it is difficult to answer these questions with a lot of work…”

Doubt about adequacy of being a psychiatric nurse and working in a psychiatric ward.

Beginners perceived a lack of ability to cope with complex clinical environments due to shortcomings in preparation for beginners, unclear duties, unit rules and routines. This situation resulted in bad feelings and impressions regarding mental health clients, feelings of inadequate profession, uncomfortable with patients, colleagues and hospital environment, a sense of loneliness and weakness, feelings of frustration, struggling with dependency and poor understanding of the meaning of patients’ behaviors. They believe that due to the expanding expectations of psychiatric nurses and increased complexity of this clinical environment in the psychiatric ward, the preparation of beginners is very important. Without this preparation, they felt uncomfortable and insecure in the psychiatric ward.

“Someone screaming, someone crying and shouting, I was waiting for bad event, no one care about this horrible situation. What kind of job do I have? Can I continue…?”

They expressed a sense of professional inadequacy and a feeling of insufficient knowledge to work in the mental health specialty. Some of them were confronted with different challenges to cope with unclear responsibilities as a psychiatric nurse and to have confidence interacting in a setting with patients who had varied psychiatric disorders.

“When a patient wanted to talk with me I really didn’t know what I should do or even what I should say?”

A frightening and non-supportive environment.

There was a lack of communication and a very formal and restricted environment, which resulted in fear of disclosure for a beginner, fear from head nurse, feeling threatened and disruptive, feeling mistrust, fear of patients and fear of loneliness. They also felt powerless and uncertain and they were scared of making mistakes as they did not have enough knowledge and experience to manage difficult situations. They were faced with a lot of challenges regarding their conception about psychiatric nursing and even nursing. They experienced a lot of fear, such as fear of unforeseeable events, fear from being infected by patients or even being affected by some psychiatric disorders. Because of stigma, it was very difficult for them to inform their friends and family about their workplace.

When my friend ask me where are you working I just tell them in hospital as a nurse, nothing more!

Some experienced that the personnel were very serious; they did not let beginners be involved in patient care and sometimes they were very offensive. The beginners felt mistrust as they were not assigned important responsibilities for providing nursing care. This resulted in limited ability to cope with such responsibilities as a psychiatric nurse.

“They don’t trust us, they should share their experience with us, we need to learn but they don’t talk and communicate with us, even they don’t let us to do something”.

A sense of imprisonment and confinement.

Different experience with different environmental milieu; a lock sense.

As a physical structure of the psychiatric ward, the doors are locked and the windows are covered with metallic fences. A nursing station is like a guardian room and is supported with long guard rails. The first-time study participants think that they are in a fully controlled prison and that there is a prisoner and warder.

“In first glance, this is like a prison. Everything is locked, patients are prisoner and nurses are warder. I scared of working in this ward during initials weeks.... I feel like I’m in jail.…. I feel I want go out but I can’t because of patients. If the door is opened someone will runaway, because patients yearned for the outside and I get agitated and so panicked by this thinking”.

Beginner nurses described the psychiatric environment as a place where they were imprisoned and confined. Their experiences were captured by feelings of suffocating, powerlessness and control.

“I feel like we’re in a place almost under full control. It's offensive and intolerable. It's confining and suffocating....”

The unclear ward routines and rules are usually poorly understood by beginners. Moreover, the strange physical structure of the psychiatric ward only exacerbated this lock sense. Participants experienced that attending a psychiatric ward is a completely different experience compared with the other nursing service units that they had experienced. They described the large enclosed nursing station that was covered with long guard rails as giving a strange feature of patients with similar uniform, oppressive ward atmosphere and intimidating and punitive, and the nurse-patient interaction being indicative of a unique, strange and different experience.

“Guard rails, roomy hall, door in the ward, lack of fresh air, light, exposure to nature, music, only gray or white colour are different from my experience gained outside or from taught courses”.

Become a psychiatric nurse: Sense of usefulness.

A sense of sympathy and compassion with patients.

After a few weeks, the situation gradually changed. They got the opportunity to be more involved in patient care and got some experience as they were exposed to a variety of patients and they learnt how to communicate with the patients. The newcomers identified that helping mental health patients brought a sense of satisfaction. Through increased knowledge, experience and relationships with patients, they got a good impression from patients and were hopeful to improve their competency and have a professional identity. They believed that they could help and were capable of making a good relationship with patients and support them as a nurse.

“...Now I think I can help, I saw different patients with different diagnosis, I know them more than before, they know I am a psychiatric nurse…I know when and how should talked them, I think I like my job because I feel good...”

They felt a sense of satisfaction and enjoyment when they talked to and when they helped their patients. Promoting therapeutic communication with patients helped them understand patients with a variety of psychiatric illnesses and diverse background and to provide effective care for them.

A sense of professional identity.

Newcomers had a good sense when they were accepted by the head nurse and other colleagues. Finally, they got the opportunity to talk with the head nurse. They had to work independently in the evenings and in night shifts, and it increased their anxiety during the initial weeks. After a few weeks, when they learnt how to communicate and interact with the patients, their confidence improved. They felt like a member of the professional group because they could use therapeutic skills to help patients. They got a sense of support and compassion from the head nurse and other personnel, a sense of intimacy with colleagues to be more important; they got a sense of usefulness and effectiveness. They believed that collegial support was essential to work in such a complex situation that encountered a lot of challenges. They admired their colleagues’ work with psychiatric patients.

“I think nursing staff are hero, there is a lot of psychiatric patients that even their family don’t want to live with them and help them, but nurses like a kind family member around the o’clock take care of them, they wash them, feed them and even buy something for them”.

DISCUSSION

This study is the first of its kind in Iran, employing a qualitative method for an in-depth understanding of beginners’ experiences. Fear and complaint in the initial few weeks, followed by a sense of imprisonment and confinement because of a unique and different environmental milieu in the psychiatric ward were the most important findings in this study. Beginner nurses were not sure about their competencies to be a psychiatric nurse, with a non-supportive environment. Gradually, when they were accepted by staff and they did something for the patients, they felt a sense of usefulness and sympathy with patients and they got a professional identity. A conceptual model was presented to show the meaning structure as well.

Participants pronounced that due to intense pressure of work, staff members do not have enough and good communication with patients. It might be more related to the fact that there is a lack of equilibrium between their duties and their time, as they have to write a lot of reports and do a lot of indirect care. However, there is a lack of time and physical restriction between the nursing station and the patients’ rooms. Accordingly, nurses do not have enough contact with patients. Newcomers with minimal experience need time and support to adjust and adopt to the new environment and position. Nurses are usually very busy and connections occur mainly within groups of nurses. This is in line with the findings of Waite,[25] which showed that patient interaction was emphasized by advance beginner nurses in the psychiatric ward, and it was expressed as their primary concerns. In the same line, Shattell et al., in their study, found that creating a therapeutic communication with patients is a central goal of psychiatric nursing. Their study showed that patients like to be listened to by the nurses, but elements of separation between nurses and patients are felt by patients as if the nurses do not care about them.[17] They found that nurses are too busy to communicate with patients and patients are bored. This implies that there is a need to be considered between work load and nurse competency in the psychiatric wards.

Doubt about adequacy of being a psychiatric nurse and working in the psychiatric ward was the other source of stress for beginner nurses. Beginners experienced a lack of ability to cope with such a complex clinical environment because of the shortcomings in preparation for beginners, unclear duties, unit rules and routines, especially in the first few weeks. This is in line with Shattell's findings that psychiatric unit rules are not clear and often poorly understood, arbitrarily assigned and unpredictably enforced.[17] Our findings showed that due to a lack of knowledge, experience and competency, beginners felt a professional inadequacy and a sense of weakness and loneliness. The study by Sharrock and Happell also supports the notion that nurses are not well educated to care for patients with psychiatric problems.[18] Experiences of lack of adequate knowledge and competency in this study echoes that advance beginner nurses in the psychiatric ward described a feeling of insufficient knowledge and skills as well.[25] This is also implied by Vivian Yong[26], stating that nursing students in clinical settings felt a sense of powerlessness and were not sure about their competency to be a nurse. All these arguments state that beginner nurses’ competencies need to be improved before starting their job at the psychiatry ward.

A frightening and non-supportive environment was the other area that beginner nurses experience due to a lack of communication and a very formal and restricted environment. This frightening and non-supportive environment could result in a wide range of distressful emotions like fear, shock, anxiety, loneliness, helplessness and uncertainty, all associated with a lack of self-confidence. The study by Waite[25] also showed that fear and anxiety have been experienced by advance beginners in the psychiatric ward. In the same line, Kilfedder found that younger and recently graduated nurses’ in the psychiatric ward experienced higher levels of depersonalization and burnout, perhaps because of the initial “shock” of the job in reality, a lack of adaptation or insecurity in the work and a perception of more role ambiguity.[14]

Another important issue that was highlighted in the current study is their conception about psychiatric nursing and their fear of stigma by friends and family members. Previous studies also support our findings regarding stigmatization of nurses who work in a psychiatric ward.[12] As Halter stated in her study, psychiatric nurses may be stigmatized by association and their close friends.[15]

Beginner nurses described the psychiatric environment as a place where they were imprisoned and confined. It may be because of the different physical structure as their experiences were captured by feelings of suffocating, powerlessness and control that were experienced by beginner nurses. Attending in a psychiatric ward is a completely different experience compared with the other nursing service units. Moreover, participants were curious regarding this new and different environmental milieu.

Gradually, and after a few weeks, beginner nurses learnt how to communicate with patients. Accordingly, helping mental health patients brought them a sense of satisfaction. Developing knowledge, experience and therapeutic communication skills could help beginners to improve their competency and professional identity. As indicated by Waite, acquisition of experience and knowledge regarding therapeutic communication skills are essential in psychiatric nursing.[25]

Additionally, there was a sense of a professional identity of which beginners had a good sense when they were accepted by the ward staff and patients. This, because they had to work independently on evening and night shifts, and this increased their anxiety during the initial weeks. Because of getting a sense of support and compassion from the head nurse and other personnel, and a sense of intimacy with colleagues, they got a sense of usefulness and effectiveness. Findings by Waite[25] and Vivan Yong[26] also showed that collegial support, having time for ventilation and developing communication between beginners and staff help them gain a sense of becoming a professional nurse.

Limitation and strength of the study

While the intention of this study was a thick description of lived experience of newcomers in the psychiatric ward, the result of this study showed that becoming a psychiatric nurse is a process and that more research is required with a focus on exploring this process by the Grounded Theory method.

Even though the findings of this study like other qualitative studies cannot be generalized, they provide an insight about how beginners experienced a psychiatric ward. Readers who find commonalities between this study environment and their own can use this study result to help newcomers and prevent early burnout among them.

CONCLUSION

This study indicated that new graduated nurses, who choose to specialize in psychiatric nursing, may face with negative perceptions and feelings due to confrontation with a new environment, patients and colleagues as well as shortcomings in the preparation.

Mentorship as a relationship between a more experienced professional and beginner, with the intention of fostering educational and professional development, is an important necessity to deal with this gap. A better understanding of what working in a psychiatric ward means for new graduated nurses could assist nursing educators, ward nursing staff and nursing managers to meet the needs of this group of the nursing community more fully. The themes identified in this study will guide nursing managers and policy makers in nursing education to improve educational and orientation plan for new graduated nurses who want to work in mental health wards.