The Iranian Psychiatric Nurses' Perception of Transition in Psychiatric Wards: A Qualitative Study.

BACKGROUND: Transition means moving from one period to another and it is usually associated with significant changes in objectives, roles, and responsibilities. Considering the challenges of the psychiatric ward, psychiatric nurses experience numerous problems, especially at the early stages of their job engagement. This study aimed to examine the perception of the Iranian psychiatric nurses in psychiatric wards and their transition period.
MATERIALS AND METHODS: The study was designed as a qualitative content analysis study in three referral hospitals in Mazandaran and Tehran, Iran 2016. Participants included 18 nurses who had experienced transition at the psychiatric ward and had at least 3 months job experience in three referral hospitals of Iran and were selected purposefully. Data were collected using unstructured interviews and analyzed using the inductive approach and conventional content analysis. To ensure the trustworthiness of the data, Guba and Lincoln's criteria were used.
RESULTS: The major themes of transition among the nurses of psychiatric wards included "inadequate preparation," "mental stress," "self-awareness and capabilities," and "the effective role of nurses' full support in adjustment."
CONCLUSIONS: The findings revealed that nurses did not have a decent transition. In this regard, educational systems must provide training courses to prepare nurses to support them in their arrival stage and to facilitate their transition. The findings of this study can help mentally prepare nurses for their preparation to perform their role and improve the quality of care.

Introduction

People constantly face internal changes and evolutions of the world throughout life.[1] For nurses, transition is a non-linear experience that shifts the person with the skills, experiences, meanings, and expectations to another position.[2] Transition is defined as a passage from one life phase, condition, or status to another. Transitions involve a process of movement and changes in fundamental life patterns, which are manifested in all individuals. Change and difference are not interchangeable, nor are they synonymous with transition. Transitions both result in change and are the result of change, all transitions involve change, whereas not all change is related to transition.[3] The transition in this study is a period in which nurses enter the psychiatric wards from other departments or immediately after graduation.

Psychiatric nurses experience considerable stress, especially at the starting point of their job in psychiatric wards and the transition stage.[45] In Iran, nursing students take a theoretical course of social and personal psychology (worth two credits), mental health nursing I and II, a practical course in mental health nursing (worth two credits).[6] With this educational background, nursing bachelor's degree holders often begin working in psychiatric wards out of necessity and only when they have no other choices. Psychiatric nurses are responsible for some aspects of clinical nursing care that includes interpersonal communication between individuals and groups and other activities.[7] It is not exactly clear how nurses experience the discussed transition under these conditions. Graduated nurses have limited opportunities to acquire sufficient experience in taking care of the mental patients, and this affects their clinical readiness.[89] According to the review of the literature, half of the nurses working in psychiatric wards bear excessive amounts of stress and emotional burnout.[4] These stresses over time cause irreparable harm to nurses, which affects the relationship between the patient and the nurse and, most importantly, causes burnout, discouragement, and job dissatisfaction among them.[10]

There are a very few studies on the experiences of transition to mental health care roles, and most of them focus on nurses' general transition from the university to clinical settings[1112] or situation-specific transition in special wards, such as intensive care units or emergency wards.[1314] A few literature reviews have examined studies on nurses' transition in psychiatric wards.[8] Some other studies used quantitative approach and examined only the previous experience of the nurse and the official acquaintance in the transition period.[15] Focusing on the literature review indicates that no study has been conducted on the transition of nurses in psychiatric wards in Iran considering their challenges and experiences.[9] Also, transition phenomena varies in different people with different experiences.[16] On this basis, and given the contextual-based nature of the transition, it is necessary to study the transition period of nurses in the psychiatric wards.[89] Therefore, considering the critic of the review of the previous studies, and the transition being context- and situation-centered, a qualitative study should be undertaken to properly and deeply understand this issue. So, this study aimed to examine the perception of the Iranian psychiatric nurses in psychiatric wards and their transition period.

Materials and Methods

This study utilized the qualitative approach. Present study is a part of the larger study with conventional content analysis method in 2016. Qualitative research allows access to the inner experiences of participants in natural areas and it is useful to study little-known phenomenon.[17]

This study was conducted in the psychiatric wards of two referral hospitals in Sari and Babol cities in Mazandaran Province in the north of Iran and a psychiatric referral hospital in Rey in Tehran Province, Iran. Sampling was carried out on nurses who were selected purposefully. The inclusion criteria consisted of being able to communicate, having experienced a transition to psychiatric wards, and having entered these wards as a nurse and worked full shifts in them for at least 3 months. Inclusion criteria included nurses who had the experience of transition in a psychiatric ward for at least 3 months in a full shift on duty. The sampling process aimed to select different gender (Male; 4, female; 14), education (bachelor; 14, Master; 4), work experience (2 years or less; 7, 3–8 years; 7, 9–14 years; 2, and 15–20 years; 2), sectors (acute; 12, chronic; 5, children; 1), and different hospitals to provide rich, wide, and deep information so as to gain possible maximum variation in sampling.

Data were collected mainly through unstructured interviews from March to November 2016. For this purpose, the researcher entered the ward, introduced herself, briefed the nurses on the study objectives, asked for their consent for participation in the study, and then proceeded with the interviews. Given the heavy workloads and the few personnel in the ward, the researcher scheduled a specific time for the interviews and revisited at that time. Interviews lasted 15–50 min.

Interviews were started with an open and general question like: What kind of experiences did you have in the early days of your career? Or please describe a working day in the first days in the work environment? Then the driving questions were used to lead the answers to the research goals, such as Please explain more! Or what do you mean? The face-to-face interviews were administered to 18 nurses and the saturation of data were reached after 15 interviews. Interviews were conducted in individual sessions, participants were in a peaceful environment at their work place at participants' working shifts and were recorded and analyzed with the consent of the participants.

In this study, data analysis method of Graneheim and Lundman (2004) was employed. First, each interview was checked and rewritten several times by the researcher and its meaningful units were derived. Repeating the interviews, the codes were compared based on the differences and similarities and were marked with labels in the conceptual categories. Finally, after careful and in-depth consideration, the compared categories were specified as theme or themes within the study.[18] An example of data analysis is presented in Table 1.

Table 1

Example of the meaning units, the preliminary codes, the preliminary categories, and the themes

Meaning units	Preliminary codes	Preliminary categories	Themes
P16: The first day I was here, I cried so much, I did not want to be employed here, I did not want to be here.P11: I generally do not like to work in a psychiatric ward.	Lack of interest in psychiatric ward	Lack of interest in working in psychiatric wards	Inadequate preparation
P17: When I came here, I liked it, generally I loved working with these patients.	Interest in working in psychiatric wards
P6: I have not worked at psychiatry ward before, I was a student. I only tried one or two biographies of patients. I did not have enough work experience.	Lack of adequate work experience in college for future work in a psychiatric ward	Understanding the previous disability to work in psychiatric wards
P18: Lack of knowledge in this area is very problematic. I had too much problems with these disease.	Negative impact of lack of awareness and knowledge on nurses’’ communicating skill

The four criteria of Guba and Lincoln's: credibility, dependability, conformability, and transferability were used for consideration of rigor.[17] In order to increase credibility, the researcher (as a trainer) had the appropriate communication and interaction with the participants (about 12 months). For the convergence of data with experience, the primary codes were checked by five participants and made corrections wherever necessary. To ensure the confirmability of the data, two qualitative researchers checked the codes and the categories that emerged from the interviews. The data were collected from nurses with maximum diversity in terms of gender, education, and various sectors.

Ethical considerations

The present study was approved by Tarbiat Modares University ethics committee and the permission of hospitals under IR.TMU.REC.1394.169 number. For each interview, the researcher explained the field and aim of the study and, if the participant was satisfied, the time and place of the interview were specified. During the interview, the researcher was committed to stopping any part of the recorded interview. Participants were assured that they were free to resign from the study. Providing feedback to the authorities and participants was conducted in compliance with the confidentiality of the names of the participants.

Results

The results of data analysis from the transition period of nurses in the mental ward include 525 preliminary codes, nine categories “lack of interest in working in psychiatric wards, understanding the previous disability to work in psychiatric ward, stress and fear of mental patients, mental conflict, gradual psychological distress, gradual empowerment and observation of impact of experience, attention and understanding the positive impact of effective communication with patients, support and cooperation of experienced colleagues, support and cooperation of head nurse” and four main themes: “inadequate preparation,” “mental stress,” “self-awareness and capabilities,” and “the effective role of nurses' full support in adjustment” [Figure 1]. Themes are presented separately and supported by contributors.

Figure 1

Conceptual themes for transition period of nurses in psychiatric wards

Inadequate preparation

One of the main themes of nurses' perceptions in transition is their inadequate preparation, so that nurses are not familiar enough when they first enter the psychiatric ward. This lack of preparation in terms is part of “the lack of interest in working in psychiatric wards and understanding previous inability for work in psychiatric wards.”

Lack of interest in working in psychiatric wards

Regarding the lack of interest in working in psychiatric wards, most participants said they are not interested in working in psychiatric wards and the reason for choosing this sector was the lack of workforce, lack of clinical work, and fewer working hours. For instance, a female participant stated that: “I was looking for a place with fewer work hours. Psychiatric ward has 50 hours less than other sectors, otherwise I wouldn't like working here.” (Participant 14).

This lack of interest was more heightened in the beginning or in transition period, as many participants said they did not like working here and they lack familiarity with psychiatric ward, but over time, they became interested in their jobs and some were not willing to relocate.

Understanding the previous disability to work in psychiatric wards

Another point about insufficient readiness was inability for work in psychiatric ward. As nurses were not prepared to communicate with the patient and they were not familiar with the principles of proper communication with patients. A male participant said: “It was really hard learning how to talk to patients at first. Self-talk and answering patients were new to me.”(P 7)

Participants mentioned the lack of attention to psychiatric training courses as the main reason for this lack of preparation. “The first day I came in. I was the only one familiar with the psychiatric patients, just a student placement, but so we did not get very serious at that time. It was a lot of fun at that time.” (P 18)

Mental stress

The concept of mental stress of psychiatric nursing means all the psychological pressures nurses face in the early stages of working in psychiatric wards or with the passage of time. Features of this concept include “stress and fear of mental patients, mental conflict, and gradual psychological distress.”

Stress and fear of mental patients

Many nurses mentioned past negative experiences of their colleagues and lack of security in the ward working with paranoid or addicted patients as the main reasons of their fear. A participant stated: “Well, if they grab you, they will beat you up, with all their strength, I was frightened more of being beaten.” (P 14)

Mental conflict

Nurses expressed their deep concern about dealing with mental patients at the beginning which was caused by lack of familiarity with the sector and lack of knowledge of how to deal with disease and depression after knowing about patients' problems. In this regard, a female participant said: “I felt depressed at the initial stage of working in a psychiatric ward. I became sad listening to their problems. I felt sorry and got upset.” (P 4)

Nurses were worried about the lack of knowledge on how to deal with patients. “How should I behave with these patients?”(P 9). Some of the participants were worried about the risk and possibility of having symptoms of mental disease. This conflict preoccupies their minds for some time and a participant said: ”I was worried about exacerbating this problem. For example, getting psychosis in postpartum. I felt I had contacted it. My thoughts were too involved.” (P 16)

Gradual psychological distress

The third dimension is progressive psychological distress; nurses working in the psychiatric ward experience mood change over time, including irritability, nervousness, and depression. In this regard, a female participant said: “I lost my tolerance by working in psychiatric wards, especially with my children.”(P 1)

Self-awareness and capabilities

The concept of self-awareness and capabilities means the nurses tried by acquiring information and raising their knowledge and awareness so as to reach self-awareness and obviate their fear of the patients and its consequent anxiety. Features of this concept include “gradual empowerment and observation of impact of experience and attention and understanding the positive impact of effective communication with patients.”

Gradual empowerment and observation of impact of experience

Over time, nurses gain experience and knowledge about their potentials. During this period, they understand the gradual empowerment and achieve the positive impact of effective communication. A participant stated: “Well, it was more about experience, after two or three months, I gained so much experience about mental patients..... after I became familiar with the situation I felt less afraid.”(P 11) Nurses mentioned “gaining experience” in communication with patients as an important factor in reducing fear. They also think the experience can help them in reducing their mental conflict about having the symptoms of mental disease.

Attention and understanding the positive impact of effective communication with patients

Another dimension of self-awareness is paying attention and understanding the positive impact of effective communication with patients, which has positive effects both on patients and nurses, reduces irritability, and increases patient comfort and confidence. As a participant said: “I told the patient something to change his/her mood and this made the patient feel better.”(P 4)

The proper relationship between nurses and patients has positive results in the treatment of patients. But the nurses say that they have a shortage of time to communicate with patients. Sometimes, too much close intimacy with mental patients could be a reason for mental conflict.

Effective role of nurses' full support in adjustment

Participants stated that full support from colleagues and cooperation of experienced partners and officials could help in transition period and adjustment. Features of this concept include “support and cooperation of experienced colleagues and support and cooperation of head nurse.”

Support and cooperation of experienced colleagues

The participants also tried to ask for help and support from their experienced colleagues and interacted with them so as to better cope with the problems in the ward and reduce their stress.

A participant stated: “Of course, my colleagues had an impact., I tried to learn from my experienced partners and to see how doctors deal with patients.” (P 9)

Support and cooperation of head nurse

In terms of help and cooperation of officials, the head nurse support was a significant help for them to cope with their fears. They stated that if the head nurse did not support us, we may not have tolerance and therefore would not be willing to continue working at the psychiatric ward. They think the head nurse support can also help them not to transfer working problems to their home and families. In this regard, a female participant said: “The head nurse called me their experiences, for example,…the head nurse spoke to me about a lot of things…. and things that the head nurse said was very helpful to me. I was very upset, the reaction and attention to behaviors made me learn.” (P 4)

Discussion

The findings suggest that nurses' perception of the transition period at the psychiatric ward included inadequate preparation, mental stress, self-awareness and capabilities, and full support from colleagues. In this regard, nurses experienced fear, stress, mental conflicts, and psychological turmoil when they started working at psychiatric wards and some perceptual elements like gaining experience over time, self-awareness, and capabilities helped them to comply.

Similar results were obtained in some other studies.[192021] In the study of Kumaran and Carney (2014) the newly qualified nurses experienced the excitement of satisfaction and a sense of accomplishment, nervousness, fear, and anxiety as soon as they become competent.[11142223] These studies are similar to the present study but due to the different conditions and characteristics of the psychiatric ward, there were some differences between these samples and other studies. The present study showed fear and stress in nurses in psychiatric wards were caused by the patients and the possibility of damage, unlike other studies, which was due to lack of competence and readiness. The nature of nurses' stress is different in the present study, so in the above-mentioned study, the stress is due to proper work and nursing performance, but in this study, it is due to the fear and stress of the patient and the possibility of injury from him.

Inadequate readiness was another aspect of nurses' experience on psychiatric wards in the present study. Meleis (2010) stated that adequate readiness can facilitate the transition process while a lack of preparation prevented it. Readiness basically deals with the primary knowledge of events related to the transition and strategy management.[3] Azimian et al. (2014) in a study reported the incompetency of university education in readiness of nurses for transition.[20] The findings of this study showed that nurses were not prepared for the transition period in psychiatric wards. This lack of readiness was in the absence of knowledge in dealing with the patient correctly.

Study of Procter et al. (2011) and Tingleff and Gildberg (2014) showed that nurses did not want to work in the psychiatric ward due to challenges such as shortage of nurses, poor career structures, and negative attitude toward mental ward nurses.[89] These results are consistent with the results of the present study.

Psychological distress was another experience of nurses in psychiatric wards in the present study. Other studies also showed that psychiatric nurses regularly deal with a stream of stressful and boring stimuli.[24] These findings were consistent with the results of present study.

The most common factors that cause stress in nurses of psychological ward are related to patients, communication between nurses and patients and to managers and employees. Some patients' behaviors and nursing interventions that can be stressful include dealing with patients with the possibility of suicide or self-injury, patients with acute symptoms, controlling the patients and physical limitations, continuous observation of patients, and the risk of hurting nurses.[5] These findings are consistent with present study in terms of the nurse–patient relationship.

The findings of this study showed that nurses feel the most fear and stress in the case of patients with suicidal risk, paranoia, drug addicts, aggressive patients, and the risk of being harmed by patient were also mentioned. The participants of this study experienced other stressful situations like intellectual engagement resulting from communication with patients and gradual psychological turmoil such as the reduced threshold of tolerance and excitability; other studies have not mentioned such cases at all.

Another experience of nurses in this study was self-awareness and capabilities. Meleis (2010) also mentioned this issue as one of the core concepts of the transition in form of awareness, involvement, engagement, and change.[3] The present study also confirms the fact that during the transition period, nurses are trying to prepare in communication with the patient, consistency with their job, and reducing mental stress after gaining experience.

The findings of present study showed that nurses of psychiatric ward thought that the close and intimate relationship with patients may result in mental conflict and they preferred to have a less friendly relationship with their patients. Procter et al. (2011) found different results; in their study nurses tended to have more of a relationship with patients, this inconsistency can be due to the differences in cultural issues.[8]

The experiences of participants in the study of Abedi et al. (2004) showed that the transition period from studentship to professional role of nursing in Iran was mostly not associated with a proper supportive environment.[25] These findings are not consistent with present study, because the participants said they received appropriate help in the transition period. This difference can be due to the particular context of the transition and the specific conditions of the psychiatric patients. The findings of Phillips et al. (2015) showed that the quality of transition is primarily linked to factors related to employer and their support at the beginning of working tasks,[19] these findings were consistent with the current study. In this study, the supportive role of colleagues and officials of psychiatric ward were emphasized.

The findings showed that nurses' perceptual elements of transition in the psychiatric ward include inadequate preparedness, psychological stress, self-awareness, and the ability and support of all-round partners. These experiences, such as fear, stress, mental conflict, and psychological distress, are the inevitable negative aspect of entering the ward. On the other hand, the nurses, with experience and time, gained positive experiences such as self-awareness and ability and, using the support of their colleagues and their departmental staff, adapted to the sector and moderated the effects of the initial negative experiences. The probability of forgetting some of the nurses' experiences due to a long time, the limitation of time, and achievement to more diverse participants were limitations of the present study that may affect the results generalization.

Conclusion

Nurses' perceptions of transition in the psychiatric ward has four aspects of inadequate preparation, mental stress, self-awareness and capabilities, and full support of colleagues. Nurses were not properly prepared to learn how to communicate with patient; so they may feel fear and stress at the initial stages of their job in psychiatric wards. After a while, these feelings fade away, and they become self-aware and capable. Therefore, it is important to design and provide training programs and more support to improve and expedite the process of transition for new nurses in the psychiatric wards. The findings can help nursing managers and policy makers know the nurses' problems during the transition period and to make new changes for their preparation and improve the quality of care. Since this study highlighted the different aspects and elements of transition period in the psychiatric ward, it can be used to develop a tool to measure nurses' perceptions of transition. Therefore, studies on tool design of psychiatric nurses' perceptions of transition are recommended.

Financial support and sponsorship

Tarbiat Modares University, Tehran, Iran

Conflicts of interest

None to declare.