Iranian Psychiatric wards from Beginner nurses'

lens: A phenomenology study

Introduction

With this belief "nurses are made on the wards, not in the
classrooms" (Cuthbertson1996) (16R) so clinical field is a vital
and irreplaceable source for nurses' learning. Nurses are faced
to a numerous types of conditions in clinical spheres which can
be source of emotional response. Some nurses described the
hospital organization as unpredictable and characterized the
emotional climate among team members unpleasant. But it is
an opportunity for them to prepare for professional
management of diverse situation; psychiatric nursing also is a
practice – based with clinical practice centered of the program.

There are negative beliefs, in general community, even in

health care professional; toward psychiatric patients. Attitudes
toward theses patients have been associated with career
choices; Stevens and Dulhunty (1992) found that nurses
demonstrated a negative desire to work in the area of
psychiatric nursing (4,…),also in a study to examine nursing
student's career preferences, psychiatric nursing was ranked in
low level (e.g. ranked from 7th to 10th from 10 possible choices)
(4,…).

A pilot study conducted by Lam, McMaster and Troup (1993)

found that education and clinical experience influence nurses'
attitudes and career choices (…).Negative attitudes toward the
psychiatric nursing field and its consumers may improve as a
consequence of positive clinical experiences in the field which
is supportive yet challenging, and exposure to the relevant
theoretical component of their undergraduate degree (4,15R,
16, 21, 24).

The negative beliefs are portrayed in different evidences which

indicate these nurses are exposed to different stresses
(4,5)which can impact on individual nurses and as well as it will
inevitably have an impact on patient care. Some documents,
taking all studies conducted outside of Iran, demonstrate that
many aspects of the work in psychiatric wards can be stressful
(1,1R,8R) especially new nurses entering the workforce most
likely will experience stressful situations in first few weeks (43).
Based on our knowledge, there is a lack of emphasis on
understanding the meaning situations for new comers and
events have for people so there is a need to understand
psychiatric nurse's experiences.

Since the most initial work experiences of new nursing

graduates occur in the context of the clinical setting within
hospital organizations, and also the uniqueness and importance
of clinical practicum to learning and attitude development in
psychiatric nursing researchers as nurse instructors and
managers decided to explore new comers nurses' experience
psychiatry wards. Moreover up to now only few investigations
could be found in our context which looks deeper into
experiences of psychiatric nurses.
This paper reports on the experiences of work in psychiatric
wards; from particular viewpoint, that of newly qualified nurses.
Unless this is achieved it is unlikely that strategies which are
designed, to provide a safe and therapeutic milieu.
Design & Method

With the use of Husserl descriptive method, it has been applied

a phenomenological nursing research approach (Benner, 1985;
Diekelmann, 1992; Dobbie, 1991; Zerwekh, 1992) to address
two fundamental questions:
1. What is the nature of the subjective experience of psychiatric
nurses?
2. How do Iranian psychiatric new comer nurses conceptualize
this experience?

Participants

Participants were selected from Razi comprehensive psychiatric

hospital,Tehran- Iran, which is the biggest psychiatric ones in
middle east with …. admission annually ,based on inclusion
criteria as : BS in nursing, work experience less than 6 months
and not work tenure in psychiatric wards beforehand (n=7 ,
one male and six females). The place of table 1 is about here.
Data collection & Analysis

Data were collected through unstructured individual interview

for every person two times (and more if it was necessary,
totaly16 interviews have been done).Interviews continued until
saturation (i.g. no new themes or essence have emerged from
the participants and the data are repeating) (Strubert2007).The
venue of interviews were selected by participants.
Interviews were taped and transcribed verbatim. The data
analysis was made according to the 7-step analysis method of
Colaizzi (1978):
Step 1: Each nurse’s interview was transcribed verbatim and
read to gain an understanding of what had been said.
Step 2: Significant phrases and statements relating to the
experiences under research were extracted from the interview.
Step 3: Meanings were formulated for each significant
statement.
Step 4: The meanings were organized into themes.
Step 5: The themes were used to provide a description of the
experiences.
Step 6: The description was returned to the individual nurses
for confirmation of validity.
Step 7: If any, new relevant data from the nurse’s validation
were incorporated.

Ethical consideration

Ethical approval was sought and once nurses signed informed

consent, they were interviewed. As with all research, the
participants were given the opportunity to decline or exit the
research process at anytime and were assured of
confidentiality.

Trustworthiness (Rigor)

To ensure pure description of data, researchers used

bracketing (i.e. researchers tried to remain neutral throughout
the investigation, with respect to belief or disbelief in the
existence of the phenomenon (Strubert2007).
Participants were asked to validate the dialogue and make
additions or subtractions, as they found necessary.
To confirm trustworthiness, the participants were again
approached to further clarity whether the overall themes were
representative of their views (member checking).
A sample of the interview text was analyzed by an
independent source to validate the themes identified.

Results

Based on participants' experiences 5 main themes were

emerged:

Feeling different experience: (1) Different experience,

(6) Novelty and new sense, (12) Curious, (28)
Orientation in ward
• Fear and being uncomfortable
- Bad feeling: (10) Bad sense, (3) uncomfortable, (13)
loneliness sense, (17) Interpretation of good and bad
sense, (18) Weakness sense
- Fear: (11) fear of patients, (16) Fear of loneliness,
(26) Fear of head nurse, (22) Fear, (34) fear from
unknowing, (7) Fear from being effected, (4) Fear
from being infected
- Lock sense (Dungeon, prison): (2) Prison
imagination, (15) Warder (Wardress) sense
- Conflict and compliant: (31) Complaint of
orientation, (33) Complaint and argument with
personnel, (14) Passiveness, (17) Interpretation of
good and bad sense, (20) Asking about cause, (30)
Insensitive toward personnel
• Feeling good , sympathy and compassion for
patients:
- Feeling good: (8) Good sense, (9) Hopefully, (21)
Sense of service and satisfaction
- Sympathy: (5) Sympathy sense, (19) Compassion,
(20) Asking about cause, (21) Sense of service and
satisfaction, (23) Sense of need's patients for help
• Feeling good toward colleagues : (24) Nurses
admire , (27) Sense of support and compassion
from head nurse, (29) Support from other personnel
• Feeling negative toward colleagues: (26) Fear
from head nurse, (25) Make amends for guilty, (30)
Insensitive toward personnel, (31) Complaint of
orientation, (33) Complaint and argument with
personnel

Brief description of each theme and subtheme:

Feeling different experience
According to study participants, coming to psychiatric ward
is a completely different experience compare to the other
nursing service units which they have experienced. They
stated that Guard rails, feature of patients, nursing office,
personnel behaviors and quality and quantity of work are
indicated a strange and different experience. (P No.6: Guard
rails, roomy hall, odor in the ward are different from my
experience in outside and classroom, it was completely
different experience).

Fear and being uncomfortable

A) Bad feeling: Most new comer nurses, in first experience
in psychiatric ward, had bad sense to: environment, patients,
staff, even relationship and interaction between them, these
could be shown by loneliness, being worried and weakness,
helplessness. (P No. 1:You can see a lot of strange windows
and doors , locked doors, restricted room and prison feature,
in a word I felt pressure and uncomfortable.).
B) Fear: Ingoing to psychiatric ward with different structure,
feature of ward and patients, personnel behaviors can be
resulted
Fear of being infected, injured, violated by patients and
different structure and strange interaction between people
apparently was experienced not having subjective
background about psychiatric ward can produce fear (I
dreaded work tell on me) (I felt fear then compassion in
touch of these clients).
C) Prisoner sense(being in jail): In psychiatric wards
specific environment, long guard rails, lock of doors,
enclosed place for patient's airing , fence for windows and, …
these can be imposed the sense of being prisoner or
guardian(I was upset for lock of doors, I felt I am a warder
besides a nurse).
D) Conflict and complaint: Having strong authority among
nursing aides and have an up to down looking as a new
comer can be resulted complaint. Staff and clients knew that,
you as a new comer have no idea. They are familiar with this
situation at least more than us. They had formal authority,
they knew routines and activities, mood drop- off, lack of
knowledge about cause of these diseases, and … due to Lack
of orientation program produced in newly personnel's mind
produce conflict and complaint of prevailing conditions. In
some time there is apparently passiveness toward
environment, patients and personnel. (I didn't have special
sense to personnel. First day, they didn't oriented me and ….
First day, I didn't receive answers of all my questions….Since
nurse – aids knew to work better, they felt they are in higher
level ….).

Feeling good, sympathy and compassion for patients

A) Feeling good: New colleagues had good sense when
they service to patients. Hope to effectiveness of treatment
and caring, good sense due to effectiveness and service.
(Colleagues' behavior was good; there is possibility for
progress rather than other hospitals….I wanted to
communicate with patients….These patients need nursing
.When we seem recompense, we can service through
nursing….).
B) Sympathy: Perceiving patients in bad conditions
produces sympathy and compassion in colleagues, asking
about why they were ill, and patients' needs for nursing
services and vum service sense to them, increase sympathy
 more and more. (Why they have become in this way, why
they have affected to this kismet…. I felt sympathy with
patients….In first confrontation, sympathy and compassion
and then satisfying their needs ….).
C) Feeling good toward colleagues: Support from
colleagues, head nurse and notice to nurses' services and
their effective and merciful attendance provide a context to
experience a good sense toward colleagues. (These [nurses]
are so heroic that they work with these patients….Head
nurse was kind and I wasn't afraid of her at all…. Ward staff
was very kind, she explained me in detail….).
D) Feeling negative toward colleagues: Irascible
behavior from some colleagues specially head nurse, some
personnel's surliness to patients ,disorientation produce
negative senses toward colleagues that effect on their first
experience and cause negative subjective background(I think
it was better if personnel behaved more kindly. They didn't
match ….I fear from head nurse…).

In a whole 3 main theme was perceived from data (Table1):

Them Subtheme Subcategory Related code

e
- Fear & Bad feeling ,Fear,
being Conflict and compliant
uncomfortab
le

- Feeling (26) Fear from head

negative nurse,
toward (25) Make amends for
colleagues guilty,
(30) Insensitive toward
Negativ personnel, (31)
e Complaint of orientation,
feeling (33) Complaint and
argument with personnel

- Fear of
working in
psychiatric
ward

- Lock sense Lock sense

- Feeling Feeling good , Sympathy

good ,
sympathy
and
compassion
for patients
Positiv
e - Feeling (24) Nurses admire,
feeling good toward (27)Sense of support
colleagues and compassion from
head nurse, (29)
Support from other
personnel

- Good sense

New - Feeling (1)Different experience,

and different (6)Novelty and new
differe experience sense, (12)Curious ,
nt (28)Orientation in ward
experie
nce
feeling

Discussion and implications:

To become a competent RN, learning should be operationalized
not only in the university classroom but also in the clinical
setting (15) .Since the period of transition allows to consolidate
the knowledge and practice skills acquired during fieldwork
practice in a working situation, so the ' real ' world of
professional practice cannot be ignored.
This study explored new nurses' experience in psychiatric
wards. In a whole three main themes were throughout the
narratives of the participants:

 New and different experience feeling due to apparent

difference in environment, patients and structure of ward
rather than other wards, nurses describe going to psychiatric
ward as a different experience.
In this study, participants described being and working in these
wards accompany with mixed and different feeling. This can be
due to strange and different structure, climate and atmosphere
in these wards, feature and behavior of patients, and even
behavior and interaction of nurses. In Waite study (2004) new
nurses entering the workforce most likely experienced stressful
situations with different emotions (Psychiatric18,
Psychiatric14). This is well documented that new RNs encounter
a sundry of emotions when entering a new role or position and
acquiring increased responsibility (?).
In our study subthemes relating to the nurses’ different
experiences included feature of patients, nursing office,
colleagues’ behaviors and quality and quantity of work. These
factors were identified in other studies as source of stress
(1,R…).
Newcomers with minimal experience need time, support, and
structured and planned orientation to adjust and acclimate
themselves to the new environment and position.
Mentorship is widely acknowledged as a relationship between a
more experienced professional and a less experienced person
the student with the intention of fostering educational and
professional development (Atkins and Williams, 1995, R11).In
Higgins' study mentors appeared to play a key role in helping
the psychiatric students to adjust and integrate into the
practice environment (11).
This strategy can be effective in beginners, to support,
guidance of developing early practice patterns, and promoting
self-confidence and competence within their profession
(psychiatric18, psychiatric13).

 Negative feeling
In common with the C. J. Kipping's (2000) research, patient
issues, relationships between, and the performance of, other
staff, administrative issues ,all were identified as stressful(1).
Negative feeling produced due to confrontation with new
environment, patients, colleagues and …(Fear and
uncomfortable , negative sense to colleagues, fear and worry
about effects of working in psychiatric ward, sense of going to
prison and being warder…).Participants stated the reception
received by head nurse and coworkers within the employment
setting, their interaction and behaviors were affected on their
feeling.
Supportive interventions, structured, planned, and
individualized orientation program adjusted to nurses' needs
can facilitate passage of nurses to overcome with
communication troubles and familiarize them with wards'
expectation and policies.
One of the aspects of their negative feeling related to fear due
to their lack of knowledge about these diseases and different
nature of disease. For example they stated they were afraid of
unpredictable behaviors in patients, being violated, and works
tell on themselves. Also in a study Sutherland and Cooper
(1990) note that psychiatric patients may be dangerous,
unpredictable, or incapable of communication and that
psychiatric nursing has a lower status than general nursing (1).
On the other hand they also mentioned these wards had a
strange environment which was look like a jail than a
therapeutic unit: enclosed spaces, lock of doors, guard rails. It
was disappointing and fearful. …

 Positive feeling due to service, good behaviors of

colleagues and… (Compassion and sympathy sense with
patients, good sense toward colleagues, good feeling…)
Participants pointed out they felt sympathy and compassion
toward patients when they perceive them in bad condition and
they wanted to provide nursing services for them. Patients'
needs for nursing services and vum service sense increase
sympathy more and more.
In Deady's (2005) study although nurses felt that their
colleagues in general nursing and the public at large probably
still perceived them to be in an inferior care discipline but the
participants perceived themselves as possessing better
interpersonal relations with their clients than their general
nurse colleagues(5).
Participants believed that colleagues' admire to nurses'
services and their effective and merciful attendance provides a
context to experience a good sense.
In the study cited earlier participants in the study appeared to
feel that the relationship with their clients is not valued or
recognized as significant by current managerial, medical, and
administrative services when decisions about service provision
for patients with a mental illness are made(5).
There appeared a need for these nurses to receive a clear
message of their values within the service, until not to feel
undervalued and stigmatized.