Journal of Psychiatric and Mental Health Nursing, 2014, 21, 536–543
The working experiences of novice psychiatric nurses in Taiwanese culture: a phenomenological study B - J . H U N G 1 M S N , X - Y. H U A N G 2 M - J . L I N 5 MSN
DNSc
, J - F. C H E N G 3
MSc
, S-J. WEI4
Ph D
&
1
Lecturer, Department of Nursing, Central Taiwan University of Science and Technology, 3Assistant Professor, Department of Nursing, China Medical University and China Medical University Hospital, Taichung, 2Professor, Department of Nursing, 4Associate Professor, Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, and 5Head Nurse, Nursing Department, Tsaotun Psychiatric Center Department of Heath, Nantou County, Taiwan
Keywords: mental health, novice
Accessible summary
psychiatric nurses, Taiwanese culture, working experiences
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Correspondence: X-Y. Huang
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Department of Nursing National Taipei University of Nursing
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and Health Sciences Taipei Peitou Distric Taiwan E-mail: [email protected] Accepted for publication: 28 October 2013 doi: 10.1111/jpm.12121
Novice psychiatric nurses work in a profession that is poorly regarded and receive insufficient training in Taiwan. Struggling, emulating, prevailing and belonging were experienced by novice nurses as they worked towards becoming a part of the psychiatric nursing staff. Awareness of problems such as lacking a sense of security, professional competency and having little understanding of mental illness is needed in order to help nurses in providing appropriate care for clients.
Abstract Novice psychiatric nurses experience heavy workloads, insufficient training and support in Taiwan. The aim of this study was to understand the working experiences of novice psychiatric nurses during their first year in a clinical setting. A qualitative phenomenological approach, using semi-structured face-to-face interviews was used. Narratives were analyzed using Colaizzi’s seven-step method. Data saturation was reached after interviews were conducted with 15 nurses based on the purposive sampling. Four themes and eight sub-themes were identified: struggling (lacking a sense of security and competency), emulating (learning the process of interaction with clients and families, learning an appropriate role from nursing staff), prevailing (developing core competency, creating a therapeutic environment) and belonging (coping with the job, becoming a part of the psychiatric nursing staff). The findings from this study demonstrate that nurses are often inadequately prepared for psychiatric nursing. They have little understanding of mental illness, are unable to communicate appropriately with clients and struggle to cope with the conditions. Our study supports the importance for helping nurses to improve their essential knowledge and skills for coping with the job and providing good quality care, particularly in the first year.
Introduction The novice nurses nowadays can take the licensure examination within weeks of graduation and enter practice as fully licensed registered nurses almost immediately (Dyess & Sherman 2009). Although newly licensed nurses have 536
the legal professional requirements of minimal competence to enter practice, substantial evidence indicates that almost all nurses lack the clinical competency to provide safe and competent practice (Del Bueno 2005, Li & Kenward 2006). In a global view, several situations, including reduced lengths of stay, staffing shortages and complex new © 2014 John Wiley & Sons Ltd
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technologies, have increased the difficulties and challenged the novice nurses to cope and stay in the clinical setting (Dyess & Sherman 2009). However, the higher turnover rate of novice nurses is still one of the major reasons for a serious shortage of nurses (Newhouse et al. 2007, Lavoie-Tremblay et al. 2008). Therefore, it is essential to understand the experiences of novice nurses when dealing with the number of skills that need to be mastered within this environment, with a view to reduce the job problems and turnover rate. In Taiwan, there are 43 262 psychiatric clients in acute and rehabilitation wards and 4742 registered psychiatric nurses (Department of Health, Executive Yuan, Taiwan 2012), which is a nurse to client ratio of 1:9.1. Internationally, California, USA and Victoria, Australia, have state legislation on minimum nurse to client ratios, for example, in California this is set at 1:6. In general, the nurse workload in Taiwan averages two to seven times more than that in the United States and other developed countries (Liang et al. 2012). Ping et al. (2008) found absenteeism in nursing work is mostly due to insufficient staff, overwork, low income, stress, the poorly regarded nature of the profession, and a lack of training. However, the area of understanding of the working experiences of novice psychiatric nurses is still limited. Therefore, this paper intends to enquire into the working experiences of registered psychiatric nurses, especially their first encounters with people suffering from mental illness.
Methods The qualitative phenomenological approach was chosen based on the philosophy of E. Husserl (Morad 2005). It focuses on the subjective and specific experiences of participants, is a rational and intuitive process and is ulti-
mately inductive in nature (Stubblefield & Murray 2002). It is important to establish epochs (bracketing) and return to the reality of the participants’ experience (Huang et al. 2006). Therefore, during the data collection and analysis, the participants were given the chance to express their point of view and ideas. The researcher was flexible and open-minded in the process of getting information from the participants. The researcher also tried to avoid being subjective in accepting or rejecting data. Reflective diaries and field logs were used to help the researcher maintain self-awareness of the data essence. Ethical considerations were approved by the ethics committee of the Institutional Review Board of the Caotun Psychiatric Center Department of Health, which is the leading psychiatric hospital in central Taiwan. The researcher received informed consent from the participants and explained the research plan completely prior to gaining their consent to participate in this study. All participants were informed that each interview would be taped and coded. Data were collected by using semi-structured faceto-face interviews. Open questions, ‘Could you please describe the experiences you have had in the job, your perceptions and feelings?’ were used. Participants were encouraged to describe their experiences as fully as possible. ‘Can you tell me more about that?’ was also used for getting more information. Each interview lasted 60–90 min. Data analysis followed the seven-step standards set by Colaizzi (1978) (Table 1). When data were analysed, the rigor of credibility, auditability, fittingness and confirmability are being achieved, along with audit trial, member check and peer debriefing (Lincoln & Guba 1985). For the credibility, the researcher was peer debriefed regarding data analysis by two professionals on the expert panel with the experiences of psychiatric nursing and qualitative research.
Table 1 Colaizzi’s (1978) seven-step procedure of data analysis Steps
Procedure of data analysis
1
All the taped interviews were read and listened numerous times until a feeling was acquired for them. For example, when the researcher read and listened to the taped interviews repeatedly, the feelings of struggling were surfaced. Significant statements relevant to the experiences of the psychiatric nurse were extracted from each transcript. For example, most nurses said that they were struggled with the fear of unexpected violence from clients. Meanings were formulated from each significant statement. During the process of data analysis, the researcher consulted the research team members as a peer debriefing process to verify that these formulated meanings are consistent with the significant statements. Clusters of themes were identified and organized from the formulated meanings. For example, having negative perceptions towards mental illness, fear of being harmed by the client with mental illness, and nurse’s family concerned about violent clients were identified through summarization into shorter and unequivocal statements. Furthermore, the sub-theme of lacking a sense of security and the theme of struggling were also identified and organized from the formulated meanings. The descriptions of experiences of psychiatric nurses who had worked for less than 1 year were written as exhaustively as possible. The researcher made the comparison between transcripts, subthemes and themes several times in order to validate the findings. The description of subthemes and themes were supported by the statements in order to further the validation of the study findings. A final validating step was achieved by asking the participants to confirm the findings. Finally, four themes and eight subthemes were achieved by showing the findings to participants for confirmation as a member check process.
2 3 4
5 6 7
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Table 2 One example of the analysis trials used for one theme based on Colaizzi’s (1978) in the study Significant statements
Formulated meanings
Subthemes
Theme
‘From watching the news showing a client with mental illness beating someone up, everyone thinks these clients are terrible . . . I thought I was certain to be hit by the clients’ (R7). ‘I was very afraid of the client . . . I just kept away from him to protect myself’ (R1). ‘My family cannot understand why I would want to work in the Psychiatric Department, mainly because of preconceptions the mass media have built associating mental illness with killing’ (R3). ‘We could have a normal conversation one moment, and then the next moment, he would get scared and chase you around trying to hit you . . ..’ (R9). ‘I was with him (client) once on my own in his room, and he started hitting me, all I could do was to grab and hold onto his hands and yell for help’ (R9). ‘My family have a prejudiced view towards mental illness, so don’t like me working with the clients with mental illness. They fear I would be beaten up’ (R4). ‘My mother has been concerned about my safety, and even up until now, hoping that I would change my job’ (R3). ‘In the training course they showed us violent clients, how to use restraint and how to deal with them but the biggest worry I have now is not knowing how to deal with clients if they become violent during my night shift. I am afraid I would not know how to immediately react to the situation’ (R4). ‘If you have any problems, you must ask the Head Nurse, or an experienced nurse to guide you. The Head Nurse taught me all kinds of things, such as how to restrain a client’ (R4). ‘Whenever I am faced with new clients, and I am unsure if they [the experienced nurses and clients] can have a meaningful conversation, I will just wait and observe them’ (R5). ‘I would listen in whenever I saw a more experienced nurse talking with a client. That way, I would know how they would talk to the client. I could learn some techniques that I could use myself next time I dealt with a client’ (R13).
Having negative perceptions towards mental illness
Lacking a sense of security
Struggling
Fear of being harmed by the client with mental illness
Nurse’s family concerned about violent clients
The novice nurses are unfamiliar with psychiatric nursing
Inability to interact
After the sub-themes and themes had been categorized, member checks were also used by asking four participants to check if the written meaning confirmed with their oral meaning. Fittingness was established by showing the participants are typical of all psychiatric nurses who had worked for less than 1 year. Confirmability was enhanced with the researcher’s neutrality, and the data were confirmed by the participants as their own view. Thus the credibility, auditability and fittingness led to enhanced confirmation of findings. Examples of the analysis trials used for the theme, struggling and sub-themes are presented in Table 2. In the study, 15 psychiatric nurses (13 women, two men), who ranged in age from 21 to 33 years and worked in acute and rehabilitation psychiatric wards of five mental hospitals in central Taiwan (Table 3), were selected using 538
Lacking competency
purposive sampling. Data saturation was reached as all the information from the participants was explored. Therefore, the continuation of further interviews was not required. The criteria included nurses who had worked for less than 1 year in a clinical setting and never had prior working experience with psychiatric clients or in psychiatric hospitals before. They had an average of 7 months experience, varying from 4 to 11 months.
Results Theme 1: struggling Struggling was commonly expressed by the nurses, and includes the sub-theme of lacking a sense of security and competency as follows: © 2014 John Wiley & Sons Ltd
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Table 3 Characteristics of samples of novice nurses in the study n=15
Sex
Age
Status
Education
Psychiatric clinical experience
Kind of psychiatric ward
R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15
F F F F F F F F F M F F F F M
27 27 23 23 33 30 21 23 28 28 24 24 23 21 34
Married Married Single Married Single Married Single Single Single Single Single Single Single Single Married
Voc. HS1 University University University Voc. HS1 Voc. HS1 Voc. HS1 Voc. HS1 University University University University Voc. HS1 Voc. HS1 University
5 months 8 months 11 months 4 months 5 months 6 months 5 months 9 months 4 months 9 months 9 months 5 months 9 months 6 months 10 months
Acute Acute Acute Rehabilitation
1
Acute Acute Acute Acute Acute Acute Acute Acute Rehabilitation Rehabilitation Acute
Voc. HS is Vocational High School; 5 years of both high school and medical training.
Sub-theme: lacking a sense of security Nurses struggled with the fear of unexpected violence from clients and being harmed within the clinical environment. We will be having a normal conversation one moment, then the next moment he will get scared, chase you around trying to hit you. (R9)
Having negative perspectives towards psychiatric clients is a direct result of the stigmas they hold when they come into the job. From watching the news showing a client with mental illness beating someone up, everyone thinks the clients with mental illness are terrible I thought I was certain to be hit by the clients with mental illness. (R7)
These stigmas affect not only the nurse at work, but also at home with their families, who were found to be concerned about their job. My family has a misunderstanding toward clients with mental illness, so don’t like me working with the clients with mental illness. They fear I would be beaten up. (R4)
Sub-theme: lacking competency Based on their basic skills and unfamiliarity with their job, they lack confidence and feel they cannot take proper care of their clients. One nurse stated her situation: I don’t know how to deal with clients if they become violent during my night shift. (R4)
Theme 2: emulating Struggling and needing to cope, the nurses talked about their experiences with other nurses, learned the process of interaction with clients and their families and learned an appropriate role from nursing staff. © 2014 John Wiley & Sons Ltd
Sub-theme: learning the process of interaction with clients and their families Nurses stated that they worked very hard to improve their ability in interacting with clients and their families to establish therapeutic relationships with them. I learned how to deal with and talk to them. (R7) Families who don’t know what on earth is going on, I treat with patience, affection and tolerance, so they may tell me their worries and fears, and I can give them some support. (R10)
Sub-theme: learning an appropriate role from nursing staff Nurses shared their learning experiences with nursing staff. One example is below: I would listen in whenever I saw a more experienced nurse talking with a client I could learn some useful skills. (R13)
Theme 3: prevailing Prevailing refers to a shift in confidence when the nurse is beginning to overcome their difficulties. They develop competence and acquire the ability to create a therapeutic environment. Sub-theme: developing competency After a period of unfamiliarity and anxiousness, they begin to gain confidence in their own ability to complete the necessary tasks. They feel confident they are able to deal with clients appropriately. Gaining confidence is quite an important factor in becoming competent. 539
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Just because a client is violent or abusive towards you doesn’t mean you can avoid contact with them. Don’t be afraid of clients arguing with, or verbally abusing you. If you try to avoid them, how would you know what they need? How could you help them? (R6) Becoming a competent nurse takes time and support from their colleagues. Support from other staff leads to an increased proficiency and confidence within the job; I would observe how other nurses took care of clients more suitably. Slowly, over time, I would learn from them until I had solved these problems. (R15) Nurses also expressed sometimes they get supports from colleagues: When my colleagues do support me, I feel it stops me from becoming negative, or stops me from being continuously negative. (R6)
The novice nurse must also participate in training exercises and learn on the job. We have a book on procedures we must go back and study again and again . . . Doing this over a long time, practising, you will learn everything you need to know, so eventually you know how to follow all the procedures. (R3)
Sub-theme: creating a therapeutic environment Creating a therapeutic environment was also mentioned by nurses in the study. They demonstrated the ability to deal with aggressive or violent behaviour from clients, and setting up a therapeutic environment for taking care of clients. The clients seem to distrust you at first. But you must continue to communicate with them. Eventually, you will see they are willing to interact with you, therefore, they have started to trust you. (R4)
An effective therapeutic environment is the goal of the psychiatric nurse. It is working with the client to bring about insight and behavioural change. At the beginning, I was afraid to approach him (the client). He then changed his attitude towards me, and was willing to talk. I felt I made great progress when he would talk to me. (R6)
Theme 4: belonging Finally, the nurses have feelings of belonging. They have achieved success in the job, and have a desire to continue working within psychiatric nursing. The nurses having had the experience of coping with the job are becoming a part of the psychiatric nursing staff. Sub-theme: coping with the job In the study, nurses expressed positivity in being able to cope with the job. Several examples as follows: 540
I can talk to clients and their families with empathy and I am able to build a trusting relationship with them. (R3) The client had hostility toward me in the beginning, but I was patient with her and cared for her. Finally, she would respond to me. I felt so great about this. (R1) I felt I had accomplished something when the client’s condition improved. (R9)
Sub-theme: becoming a part of the psychiatric nursing staff They use their initiative to care for their clients and are trusted by the other staff to be able to perform what is required of them. Before I go to work I think, ‘What will happen today?’ There is no way to predict what kinds of situations will arise, it is always a pleasant surprise, and you figure it out along the way. (R14) I didn’t think the clients were actually that bad. Of course sometimes they would lose control and have periods when their mood swings, but even then it was still ok. I just think they are not too different to normal people. (R13)
Discussion The aim of this study was to explore the working experiences of novice psychiatric nurses in the first year, and results were captured in four themes: struggling, emulating, prevailing and belonging. Similarly, the study findings support the conceptual framework that novice nurses move through three ‘stages: doing, knowing, and being’during their first 12 months working experiences (Duchscher 2008). A qualitative descriptive research based on 35 new graduate nurses from four medical centres in Taiwan, identified three themes as process of overwhelming chaos, learning by doing and being as insider (Feng & Tsai 2012). These findings have shown the dynamic process regarding the coping process no matter what kinds of nursing professional. When novice nurses just entered the workplace, they suffered many difficulties and challenges because they lack of working experience. Then, they had to learn how to deal with the clients and their job. During the learning process, novice nurses are getting more confidence when they begin to overcome their difficulties. Finally, coping with the job and becoming a part of the nursing staff will be gained when novice nurses achieve the belonging stage. Based on the novice nurses’ basic skills and unfamiliarity with their job, they usually lack confidence for caring properly for their clients. The situations not only were strongly supported in this study but also several researchers (Halfer © 2014 John Wiley & Sons Ltd
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& Graf 2006, McKenna & Newton 2008, Kelly & Ahern 2009). Therefore, how to help novice nurses effectively overcome the working difficulties is still an extremely important issue for the nursing profession. Gratifyingly, several education programmes were successful transition for the novice nurses (Young et al. 2008, Goode et al. 2009, Romyn et al. 2009, Strauss 2009, Kaddoura 2010). However, regardless of how well prepared nurses are, there will always be issues and problems as they shift from students to nurses. This skill and knowledge shortage can be solved to a certain extent by imitation of more experienced staff. The difficulties in transition from student to nurse can be addressed through a preceptorship programme. To make this work, the director of nursing at each hospital should be charged with the task of assisting novices to become accustomed to their responsibilities by working with an appropriate preceptor. This was supported by Happell (2009), who described how the strategy of preceptorship benefits the clinical education of the nurses. Arvidsson (2000) also suggested the preceptor should supervise the novice nurse and hold group discussions designed to find problems and teach how to deal with them to avoid a maladaptation of ideas. In the study, the results found that most novice psychiatric nurses have feelings of fear and a poor sense of security. Gentle (1996) also found new mental health nurses were inadequately prepared when it came to security, and they are afraid of violent and aggressive behaviour, and this was a major stressor from their work (Currid 2008). Nurses need to play an important role in creating a therapeutic milieu (Whittington & McLaughlin 2000). The development of trust between client and nurse is of paramount importance in establishing relationships (Johansson & Eklund 2004, Ping et al. 2008). However, if they bring their misconceptions to their job, this trusting environment is difficult to establish. This reflects the misconceptions and negative attitudes held by the nurse and the inability to interact appropriately (Whittington & McLaughlin 2000, Ping et al. 2008). The fact that this is a recurring theme indicates the need for a change in strategy. They have to improve individual awareness and overcome perceptions in society to avoid stigmatizing clients. In this way, a therapeutic environment can be developed (Kukulu & Ergun 2007). The novice nurses should be given a thorough introduction to the different kinds of mental illness and their symptoms, as well as what may stir different clients to violence and how to prevent that from happening. They must be taught how to deal with the violent clients appropriately (Arvidsson 2000). Knowledge and skills of crisis intervention would help novice nurses adapt to the new environment. Other studies have also identified that beginners of psychiatric © 2014 John Wiley & Sons Ltd
nursing need to be given training programmes to manage violence. (Cleary et al. 2005, McCloughen & O’Brien 2005, Hsieh et al. 2006). Hage et al. (2009) found nursing staff can assist in achieving a systematic improvement in the treatment outcomes of existing intervention programmes for the prevention of aggression. The novice nurse who enters into psychiatric nursing must quickly reach a level of professional competence and meet the expectations of their clients (Cleary et al. 2005, McCloughen & O’Brien 2005, Ping et al. 2008). Duxbury & Whittington (2005) found that perceived environmental conditions and poor communication were significant precursors of aggressive behaviour in clients. However, communication with clients was perhaps the area that most novice nurses had the most trouble confronting. Given the importance of trust in this process of establishing relationships and interaction, the novice nurses must play an active role by being in contact with clients. The participants in this study felt inadequately prepared for communicating with people with mental illness, and the nurses felt the need to enhance their therapeutic communicative skills. The best way to reduce anxiety is by teaching them the required counselling skills (Long & Reid 1996, Sleeper & Thompson 2008), which would include empathy and reflecting skills, listening and concentration skills. The ability for practising communication skills prior to entering psychiatric settings can improve effective therapeutic communication skills and lower the anxiety of nurses (Sleeper & Thompson 2008). Novice nurses must use genuineness, respect and empathic understanding to meet the client’s needs, and these core conditions are identified by Carl Rogers (Moon 2007). Education and training are essential for developing more positive attitudes. Role play and group discussion are also good learning methods for new psychiatric nurses. Although learning in this environment may be slower, confidence would be built. Some of these initial difficulties would be addressed by having a preceptor, by imitation and a certain amount of trial and error. However, some issues should not be left to chance, and classroom training would help avoid this possibility. This study also found the importance of students developing professionally and coping rationally in a clinical setting. This includes the novice nurse’s self-awareness. Self-awareness is important when trying to cope with the stress of the job, which is a common experience as they transform from students into professional nurses. Writing a reflective journal would be an innovative strategy (Williams et al. 2009). Some participants expressed that they were angry about the actions of clients and their responses were not justified by reality, but they were able to examine their feelings and reactions, and improve as a communicator. In this study, a 541
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good understanding and acceptance of self allows the participants to acknowledge clients’ differences and uniqueness. To achieve self-awareness some studies suggest the nurses should develop their level of emotional intelligence (EI) to help solve problems and make decisions (Mayer et al. 1990). Akerjordet & Severinsson (2004) argue the EI of a mental health nurse must mature and develop, as this process of emotional learning is central to achieving competence. However, the nurse must accept their limitations as well as awareness of their emotions. This is also supported by Arvidsson (2000) and Hung et al. (2009). As the psychiatric nurse, they must cultivate effective nursing attitudes for assisting people with mental illness (Katakura et al. 2010). This study also found that the novice nurses who have a positive attitude are more likely to use their initiative to take care of the clients. Hsieh et al. (2004) also found that the confrontational, optimistic and self-reliant coping styles were positively correlated to their personal accomplishment, but nurses need time to develop and define these parts of their personalities. Throughout this process, they need the support of experienced nurses, and if available, their preceptor. Together, they can analyse the nurse’s behaviour and assess personal strengths and limitations. Finally, the novice nurses in this study identified themselves in the role of registered nurses and, because of this, had increased job satisfaction. We found most nurses discovered an interest in the work, which is similar to Cleary et al.’s (2005) findings who found two thirds of respondents still wanted to be a psychiatric nurse after some time in the field. However, Currid (2008) stresses that some staff had difficulties they had yet to overcome. This may be due to being inadequately prepared. Becoming part of the staff requires that each nurse is, and is confident that every other
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Conclusion This study is the first research to explore the working experiences of novice psychiatric nurses in the first year in Taiwan. The findings show that the nurses are inadequately prepared for psychiatric nursing. Nurses were found to have little or minimal understanding of mental illness, and most of their knowledge seems to have come from the misconceptions popularized in the media or from influences from their families. Nurses were, perhaps as an extension from the previous point as well as insufficient training, unable to communicate appropriately with clients. Furthermore, with most psychiatric skills that are needed having to be learnt in the already stressful environment on the job, the novice nurses struggled to cope with the job and the conditions. We hope to have drawn focus to a foundation of training that needs to be improved. Based on our results, it is suggested that the nursing curriculums need to help the novice psychiatric nurses to improve their clinical practice, to enhance therapeutic communicative techniques and to use positive coping strategies. It is also important to establish a nursing preceptorship programme for novice psychiatric nurses to become familiar with and acclimatized to the therapeutic environment.
Limitations of the Study The sampling of the study was from a small group of nurses, albeit from different hospitals. Therefore, these experiences cannot be generalized to the large population of nurses and their experiences of clinical practice. Research was also contained to central Taiwan, so it may not be representative of other areas.
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The working experiences of novice psychiatric nurses in Taiwanese culture: a phenomenological study B - J . H U N G 1 M S N , X - Y. H U A N G 2 M - J . L I N 5 MSN
DNSc
, J - F. C H E N G 3
MSc
, S-J. WEI4
Ph D
&
1
Lecturer, Department of Nursing, Central Taiwan University of Science and Technology, 3Assistant Professor, Department of Nursing, China Medical University and China Medical University Hospital, Taichung, 2Professor, Department of Nursing, 4Associate Professor, Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, and 5Head Nurse, Nursing Department, Tsaotun Psychiatric Center Department of Heath, Nantou County, Taiwan
Keywords: mental health, novice
Accessible summary
psychiatric nurses, Taiwanese culture, working experiences
•
Correspondence: X-Y. Huang
•
Department of Nursing National Taipei University of Nursing
•
and Health Sciences Taipei Peitou Distric Taiwan E-mail: [email protected] Accepted for publication: 28 October 2013 doi: 10.1111/jpm.12121
Novice psychiatric nurses work in a profession that is poorly regarded and receive insufficient training in Taiwan. Struggling, emulating, prevailing and belonging were experienced by novice nurses as they worked towards becoming a part of the psychiatric nursing staff. Awareness of problems such as lacking a sense of security, professional competency and having little understanding of mental illness is needed in order to help nurses in providing appropriate care for clients.
Abstract Novice psychiatric nurses experience heavy workloads, insufficient training and support in Taiwan. The aim of this study was to understand the working experiences of novice psychiatric nurses during their first year in a clinical setting. A qualitative phenomenological approach, using semi-structured face-to-face interviews was used. Narratives were analyzed using Colaizzi’s seven-step method. Data saturation was reached after interviews were conducted with 15 nurses based on the purposive sampling. Four themes and eight sub-themes were identified: struggling (lacking a sense of security and competency), emulating (learning the process of interaction with clients and families, learning an appropriate role from nursing staff), prevailing (developing core competency, creating a therapeutic environment) and belonging (coping with the job, becoming a part of the psychiatric nursing staff). The findings from this study demonstrate that nurses are often inadequately prepared for psychiatric nursing. They have little understanding of mental illness, are unable to communicate appropriately with clients and struggle to cope with the conditions. Our study supports the importance for helping nurses to improve their essential knowledge and skills for coping with the job and providing good quality care, particularly in the first year.
Introduction The novice nurses nowadays can take the licensure examination within weeks of graduation and enter practice as fully licensed registered nurses almost immediately (Dyess & Sherman 2009). Although newly licensed nurses have 536
the legal professional requirements of minimal competence to enter practice, substantial evidence indicates that almost all nurses lack the clinical competency to provide safe and competent practice (Del Bueno 2005, Li & Kenward 2006). In a global view, several situations, including reduced lengths of stay, staffing shortages and complex new © 2014 John Wiley & Sons Ltd
Novice psychiatric nurses’ working experiences
technologies, have increased the difficulties and challenged the novice nurses to cope and stay in the clinical setting (Dyess & Sherman 2009). However, the higher turnover rate of novice nurses is still one of the major reasons for a serious shortage of nurses (Newhouse et al. 2007, Lavoie-Tremblay et al. 2008). Therefore, it is essential to understand the experiences of novice nurses when dealing with the number of skills that need to be mastered within this environment, with a view to reduce the job problems and turnover rate. In Taiwan, there are 43 262 psychiatric clients in acute and rehabilitation wards and 4742 registered psychiatric nurses (Department of Health, Executive Yuan, Taiwan 2012), which is a nurse to client ratio of 1:9.1. Internationally, California, USA and Victoria, Australia, have state legislation on minimum nurse to client ratios, for example, in California this is set at 1:6. In general, the nurse workload in Taiwan averages two to seven times more than that in the United States and other developed countries (Liang et al. 2012). Ping et al. (2008) found absenteeism in nursing work is mostly due to insufficient staff, overwork, low income, stress, the poorly regarded nature of the profession, and a lack of training. However, the area of understanding of the working experiences of novice psychiatric nurses is still limited. Therefore, this paper intends to enquire into the working experiences of registered psychiatric nurses, especially their first encounters with people suffering from mental illness.
Methods The qualitative phenomenological approach was chosen based on the philosophy of E. Husserl (Morad 2005). It focuses on the subjective and specific experiences of participants, is a rational and intuitive process and is ulti-
mately inductive in nature (Stubblefield & Murray 2002). It is important to establish epochs (bracketing) and return to the reality of the participants’ experience (Huang et al. 2006). Therefore, during the data collection and analysis, the participants were given the chance to express their point of view and ideas. The researcher was flexible and open-minded in the process of getting information from the participants. The researcher also tried to avoid being subjective in accepting or rejecting data. Reflective diaries and field logs were used to help the researcher maintain self-awareness of the data essence. Ethical considerations were approved by the ethics committee of the Institutional Review Board of the Caotun Psychiatric Center Department of Health, which is the leading psychiatric hospital in central Taiwan. The researcher received informed consent from the participants and explained the research plan completely prior to gaining their consent to participate in this study. All participants were informed that each interview would be taped and coded. Data were collected by using semi-structured faceto-face interviews. Open questions, ‘Could you please describe the experiences you have had in the job, your perceptions and feelings?’ were used. Participants were encouraged to describe their experiences as fully as possible. ‘Can you tell me more about that?’ was also used for getting more information. Each interview lasted 60–90 min. Data analysis followed the seven-step standards set by Colaizzi (1978) (Table 1). When data were analysed, the rigor of credibility, auditability, fittingness and confirmability are being achieved, along with audit trial, member check and peer debriefing (Lincoln & Guba 1985). For the credibility, the researcher was peer debriefed regarding data analysis by two professionals on the expert panel with the experiences of psychiatric nursing and qualitative research.
Table 1 Colaizzi’s (1978) seven-step procedure of data analysis Steps
Procedure of data analysis
1
All the taped interviews were read and listened numerous times until a feeling was acquired for them. For example, when the researcher read and listened to the taped interviews repeatedly, the feelings of struggling were surfaced. Significant statements relevant to the experiences of the psychiatric nurse were extracted from each transcript. For example, most nurses said that they were struggled with the fear of unexpected violence from clients. Meanings were formulated from each significant statement. During the process of data analysis, the researcher consulted the research team members as a peer debriefing process to verify that these formulated meanings are consistent with the significant statements. Clusters of themes were identified and organized from the formulated meanings. For example, having negative perceptions towards mental illness, fear of being harmed by the client with mental illness, and nurse’s family concerned about violent clients were identified through summarization into shorter and unequivocal statements. Furthermore, the sub-theme of lacking a sense of security and the theme of struggling were also identified and organized from the formulated meanings. The descriptions of experiences of psychiatric nurses who had worked for less than 1 year were written as exhaustively as possible. The researcher made the comparison between transcripts, subthemes and themes several times in order to validate the findings. The description of subthemes and themes were supported by the statements in order to further the validation of the study findings. A final validating step was achieved by asking the participants to confirm the findings. Finally, four themes and eight subthemes were achieved by showing the findings to participants for confirmation as a member check process.
2 3 4
5 6 7
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Table 2 One example of the analysis trials used for one theme based on Colaizzi’s (1978) in the study Significant statements
Formulated meanings
Subthemes
Theme
‘From watching the news showing a client with mental illness beating someone up, everyone thinks these clients are terrible . . . I thought I was certain to be hit by the clients’ (R7). ‘I was very afraid of the client . . . I just kept away from him to protect myself’ (R1). ‘My family cannot understand why I would want to work in the Psychiatric Department, mainly because of preconceptions the mass media have built associating mental illness with killing’ (R3). ‘We could have a normal conversation one moment, and then the next moment, he would get scared and chase you around trying to hit you . . ..’ (R9). ‘I was with him (client) once on my own in his room, and he started hitting me, all I could do was to grab and hold onto his hands and yell for help’ (R9). ‘My family have a prejudiced view towards mental illness, so don’t like me working with the clients with mental illness. They fear I would be beaten up’ (R4). ‘My mother has been concerned about my safety, and even up until now, hoping that I would change my job’ (R3). ‘In the training course they showed us violent clients, how to use restraint and how to deal with them but the biggest worry I have now is not knowing how to deal with clients if they become violent during my night shift. I am afraid I would not know how to immediately react to the situation’ (R4). ‘If you have any problems, you must ask the Head Nurse, or an experienced nurse to guide you. The Head Nurse taught me all kinds of things, such as how to restrain a client’ (R4). ‘Whenever I am faced with new clients, and I am unsure if they [the experienced nurses and clients] can have a meaningful conversation, I will just wait and observe them’ (R5). ‘I would listen in whenever I saw a more experienced nurse talking with a client. That way, I would know how they would talk to the client. I could learn some techniques that I could use myself next time I dealt with a client’ (R13).
Having negative perceptions towards mental illness
Lacking a sense of security
Struggling
Fear of being harmed by the client with mental illness
Nurse’s family concerned about violent clients
The novice nurses are unfamiliar with psychiatric nursing
Inability to interact
After the sub-themes and themes had been categorized, member checks were also used by asking four participants to check if the written meaning confirmed with their oral meaning. Fittingness was established by showing the participants are typical of all psychiatric nurses who had worked for less than 1 year. Confirmability was enhanced with the researcher’s neutrality, and the data were confirmed by the participants as their own view. Thus the credibility, auditability and fittingness led to enhanced confirmation of findings. Examples of the analysis trials used for the theme, struggling and sub-themes are presented in Table 2. In the study, 15 psychiatric nurses (13 women, two men), who ranged in age from 21 to 33 years and worked in acute and rehabilitation psychiatric wards of five mental hospitals in central Taiwan (Table 3), were selected using 538
Lacking competency
purposive sampling. Data saturation was reached as all the information from the participants was explored. Therefore, the continuation of further interviews was not required. The criteria included nurses who had worked for less than 1 year in a clinical setting and never had prior working experience with psychiatric clients or in psychiatric hospitals before. They had an average of 7 months experience, varying from 4 to 11 months.
Results Theme 1: struggling Struggling was commonly expressed by the nurses, and includes the sub-theme of lacking a sense of security and competency as follows: © 2014 John Wiley & Sons Ltd
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Table 3 Characteristics of samples of novice nurses in the study n=15
Sex
Age
Status
Education
Psychiatric clinical experience
Kind of psychiatric ward
R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15
F F F F F F F F F M F F F F M
27 27 23 23 33 30 21 23 28 28 24 24 23 21 34
Married Married Single Married Single Married Single Single Single Single Single Single Single Single Married
Voc. HS1 University University University Voc. HS1 Voc. HS1 Voc. HS1 Voc. HS1 University University University University Voc. HS1 Voc. HS1 University
5 months 8 months 11 months 4 months 5 months 6 months 5 months 9 months 4 months 9 months 9 months 5 months 9 months 6 months 10 months
Acute Acute Acute Rehabilitation
1
Acute Acute Acute Acute Acute Acute Acute Acute Rehabilitation Rehabilitation Acute
Voc. HS is Vocational High School; 5 years of both high school and medical training.
Sub-theme: lacking a sense of security Nurses struggled with the fear of unexpected violence from clients and being harmed within the clinical environment. We will be having a normal conversation one moment, then the next moment he will get scared, chase you around trying to hit you. (R9)
Having negative perspectives towards psychiatric clients is a direct result of the stigmas they hold when they come into the job. From watching the news showing a client with mental illness beating someone up, everyone thinks the clients with mental illness are terrible I thought I was certain to be hit by the clients with mental illness. (R7)
These stigmas affect not only the nurse at work, but also at home with their families, who were found to be concerned about their job. My family has a misunderstanding toward clients with mental illness, so don’t like me working with the clients with mental illness. They fear I would be beaten up. (R4)
Sub-theme: lacking competency Based on their basic skills and unfamiliarity with their job, they lack confidence and feel they cannot take proper care of their clients. One nurse stated her situation: I don’t know how to deal with clients if they become violent during my night shift. (R4)
Theme 2: emulating Struggling and needing to cope, the nurses talked about their experiences with other nurses, learned the process of interaction with clients and their families and learned an appropriate role from nursing staff. © 2014 John Wiley & Sons Ltd
Sub-theme: learning the process of interaction with clients and their families Nurses stated that they worked very hard to improve their ability in interacting with clients and their families to establish therapeutic relationships with them. I learned how to deal with and talk to them. (R7) Families who don’t know what on earth is going on, I treat with patience, affection and tolerance, so they may tell me their worries and fears, and I can give them some support. (R10)
Sub-theme: learning an appropriate role from nursing staff Nurses shared their learning experiences with nursing staff. One example is below: I would listen in whenever I saw a more experienced nurse talking with a client I could learn some useful skills. (R13)
Theme 3: prevailing Prevailing refers to a shift in confidence when the nurse is beginning to overcome their difficulties. They develop competence and acquire the ability to create a therapeutic environment. Sub-theme: developing competency After a period of unfamiliarity and anxiousness, they begin to gain confidence in their own ability to complete the necessary tasks. They feel confident they are able to deal with clients appropriately. Gaining confidence is quite an important factor in becoming competent. 539
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Just because a client is violent or abusive towards you doesn’t mean you can avoid contact with them. Don’t be afraid of clients arguing with, or verbally abusing you. If you try to avoid them, how would you know what they need? How could you help them? (R6) Becoming a competent nurse takes time and support from their colleagues. Support from other staff leads to an increased proficiency and confidence within the job; I would observe how other nurses took care of clients more suitably. Slowly, over time, I would learn from them until I had solved these problems. (R15) Nurses also expressed sometimes they get supports from colleagues: When my colleagues do support me, I feel it stops me from becoming negative, or stops me from being continuously negative. (R6)
The novice nurse must also participate in training exercises and learn on the job. We have a book on procedures we must go back and study again and again . . . Doing this over a long time, practising, you will learn everything you need to know, so eventually you know how to follow all the procedures. (R3)
Sub-theme: creating a therapeutic environment Creating a therapeutic environment was also mentioned by nurses in the study. They demonstrated the ability to deal with aggressive or violent behaviour from clients, and setting up a therapeutic environment for taking care of clients. The clients seem to distrust you at first. But you must continue to communicate with them. Eventually, you will see they are willing to interact with you, therefore, they have started to trust you. (R4)
An effective therapeutic environment is the goal of the psychiatric nurse. It is working with the client to bring about insight and behavioural change. At the beginning, I was afraid to approach him (the client). He then changed his attitude towards me, and was willing to talk. I felt I made great progress when he would talk to me. (R6)
Theme 4: belonging Finally, the nurses have feelings of belonging. They have achieved success in the job, and have a desire to continue working within psychiatric nursing. The nurses having had the experience of coping with the job are becoming a part of the psychiatric nursing staff. Sub-theme: coping with the job In the study, nurses expressed positivity in being able to cope with the job. Several examples as follows: 540
I can talk to clients and their families with empathy and I am able to build a trusting relationship with them. (R3) The client had hostility toward me in the beginning, but I was patient with her and cared for her. Finally, she would respond to me. I felt so great about this. (R1) I felt I had accomplished something when the client’s condition improved. (R9)
Sub-theme: becoming a part of the psychiatric nursing staff They use their initiative to care for their clients and are trusted by the other staff to be able to perform what is required of them. Before I go to work I think, ‘What will happen today?’ There is no way to predict what kinds of situations will arise, it is always a pleasant surprise, and you figure it out along the way. (R14) I didn’t think the clients were actually that bad. Of course sometimes they would lose control and have periods when their mood swings, but even then it was still ok. I just think they are not too different to normal people. (R13)
Discussion The aim of this study was to explore the working experiences of novice psychiatric nurses in the first year, and results were captured in four themes: struggling, emulating, prevailing and belonging. Similarly, the study findings support the conceptual framework that novice nurses move through three ‘stages: doing, knowing, and being’during their first 12 months working experiences (Duchscher 2008). A qualitative descriptive research based on 35 new graduate nurses from four medical centres in Taiwan, identified three themes as process of overwhelming chaos, learning by doing and being as insider (Feng & Tsai 2012). These findings have shown the dynamic process regarding the coping process no matter what kinds of nursing professional. When novice nurses just entered the workplace, they suffered many difficulties and challenges because they lack of working experience. Then, they had to learn how to deal with the clients and their job. During the learning process, novice nurses are getting more confidence when they begin to overcome their difficulties. Finally, coping with the job and becoming a part of the nursing staff will be gained when novice nurses achieve the belonging stage. Based on the novice nurses’ basic skills and unfamiliarity with their job, they usually lack confidence for caring properly for their clients. The situations not only were strongly supported in this study but also several researchers (Halfer © 2014 John Wiley & Sons Ltd
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& Graf 2006, McKenna & Newton 2008, Kelly & Ahern 2009). Therefore, how to help novice nurses effectively overcome the working difficulties is still an extremely important issue for the nursing profession. Gratifyingly, several education programmes were successful transition for the novice nurses (Young et al. 2008, Goode et al. 2009, Romyn et al. 2009, Strauss 2009, Kaddoura 2010). However, regardless of how well prepared nurses are, there will always be issues and problems as they shift from students to nurses. This skill and knowledge shortage can be solved to a certain extent by imitation of more experienced staff. The difficulties in transition from student to nurse can be addressed through a preceptorship programme. To make this work, the director of nursing at each hospital should be charged with the task of assisting novices to become accustomed to their responsibilities by working with an appropriate preceptor. This was supported by Happell (2009), who described how the strategy of preceptorship benefits the clinical education of the nurses. Arvidsson (2000) also suggested the preceptor should supervise the novice nurse and hold group discussions designed to find problems and teach how to deal with them to avoid a maladaptation of ideas. In the study, the results found that most novice psychiatric nurses have feelings of fear and a poor sense of security. Gentle (1996) also found new mental health nurses were inadequately prepared when it came to security, and they are afraid of violent and aggressive behaviour, and this was a major stressor from their work (Currid 2008). Nurses need to play an important role in creating a therapeutic milieu (Whittington & McLaughlin 2000). The development of trust between client and nurse is of paramount importance in establishing relationships (Johansson & Eklund 2004, Ping et al. 2008). However, if they bring their misconceptions to their job, this trusting environment is difficult to establish. This reflects the misconceptions and negative attitudes held by the nurse and the inability to interact appropriately (Whittington & McLaughlin 2000, Ping et al. 2008). The fact that this is a recurring theme indicates the need for a change in strategy. They have to improve individual awareness and overcome perceptions in society to avoid stigmatizing clients. In this way, a therapeutic environment can be developed (Kukulu & Ergun 2007). The novice nurses should be given a thorough introduction to the different kinds of mental illness and their symptoms, as well as what may stir different clients to violence and how to prevent that from happening. They must be taught how to deal with the violent clients appropriately (Arvidsson 2000). Knowledge and skills of crisis intervention would help novice nurses adapt to the new environment. Other studies have also identified that beginners of psychiatric © 2014 John Wiley & Sons Ltd
nursing need to be given training programmes to manage violence. (Cleary et al. 2005, McCloughen & O’Brien 2005, Hsieh et al. 2006). Hage et al. (2009) found nursing staff can assist in achieving a systematic improvement in the treatment outcomes of existing intervention programmes for the prevention of aggression. The novice nurse who enters into psychiatric nursing must quickly reach a level of professional competence and meet the expectations of their clients (Cleary et al. 2005, McCloughen & O’Brien 2005, Ping et al. 2008). Duxbury & Whittington (2005) found that perceived environmental conditions and poor communication were significant precursors of aggressive behaviour in clients. However, communication with clients was perhaps the area that most novice nurses had the most trouble confronting. Given the importance of trust in this process of establishing relationships and interaction, the novice nurses must play an active role by being in contact with clients. The participants in this study felt inadequately prepared for communicating with people with mental illness, and the nurses felt the need to enhance their therapeutic communicative skills. The best way to reduce anxiety is by teaching them the required counselling skills (Long & Reid 1996, Sleeper & Thompson 2008), which would include empathy and reflecting skills, listening and concentration skills. The ability for practising communication skills prior to entering psychiatric settings can improve effective therapeutic communication skills and lower the anxiety of nurses (Sleeper & Thompson 2008). Novice nurses must use genuineness, respect and empathic understanding to meet the client’s needs, and these core conditions are identified by Carl Rogers (Moon 2007). Education and training are essential for developing more positive attitudes. Role play and group discussion are also good learning methods for new psychiatric nurses. Although learning in this environment may be slower, confidence would be built. Some of these initial difficulties would be addressed by having a preceptor, by imitation and a certain amount of trial and error. However, some issues should not be left to chance, and classroom training would help avoid this possibility. This study also found the importance of students developing professionally and coping rationally in a clinical setting. This includes the novice nurse’s self-awareness. Self-awareness is important when trying to cope with the stress of the job, which is a common experience as they transform from students into professional nurses. Writing a reflective journal would be an innovative strategy (Williams et al. 2009). Some participants expressed that they were angry about the actions of clients and their responses were not justified by reality, but they were able to examine their feelings and reactions, and improve as a communicator. In this study, a 541
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good understanding and acceptance of self allows the participants to acknowledge clients’ differences and uniqueness. To achieve self-awareness some studies suggest the nurses should develop their level of emotional intelligence (EI) to help solve problems and make decisions (Mayer et al. 1990). Akerjordet & Severinsson (2004) argue the EI of a mental health nurse must mature and develop, as this process of emotional learning is central to achieving competence. However, the nurse must accept their limitations as well as awareness of their emotions. This is also supported by Arvidsson (2000) and Hung et al. (2009). As the psychiatric nurse, they must cultivate effective nursing attitudes for assisting people with mental illness (Katakura et al. 2010). This study also found that the novice nurses who have a positive attitude are more likely to use their initiative to take care of the clients. Hsieh et al. (2004) also found that the confrontational, optimistic and self-reliant coping styles were positively correlated to their personal accomplishment, but nurses need time to develop and define these parts of their personalities. Throughout this process, they need the support of experienced nurses, and if available, their preceptor. Together, they can analyse the nurse’s behaviour and assess personal strengths and limitations. Finally, the novice nurses in this study identified themselves in the role of registered nurses and, because of this, had increased job satisfaction. We found most nurses discovered an interest in the work, which is similar to Cleary et al.’s (2005) findings who found two thirds of respondents still wanted to be a psychiatric nurse after some time in the field. However, Currid (2008) stresses that some staff had difficulties they had yet to overcome. This may be due to being inadequately prepared. Becoming part of the staff requires that each nurse is, and is confident that every other
References Akerjordet K. & Severinsson E. (2004) Emotional intelligence in mental health nurses talking about practice. International Journal of Mental Health Nursing 13, 164–170. Arvidsson B. (2000) Psychiatric nurses’ conceptions of how group supervision in nursing care influences their professional competence. Journal of Nursing Management 8, 175– 185.
nurse is, competent and capable of performing all tasks necessary as situations arise.
Conclusion This study is the first research to explore the working experiences of novice psychiatric nurses in the first year in Taiwan. The findings show that the nurses are inadequately prepared for psychiatric nursing. Nurses were found to have little or minimal understanding of mental illness, and most of their knowledge seems to have come from the misconceptions popularized in the media or from influences from their families. Nurses were, perhaps as an extension from the previous point as well as insufficient training, unable to communicate appropriately with clients. Furthermore, with most psychiatric skills that are needed having to be learnt in the already stressful environment on the job, the novice nurses struggled to cope with the job and the conditions. We hope to have drawn focus to a foundation of training that needs to be improved. Based on our results, it is suggested that the nursing curriculums need to help the novice psychiatric nurses to improve their clinical practice, to enhance therapeutic communicative techniques and to use positive coping strategies. It is also important to establish a nursing preceptorship programme for novice psychiatric nurses to become familiar with and acclimatized to the therapeutic environment.
Limitations of the Study The sampling of the study was from a small group of nurses, albeit from different hospitals. Therefore, these experiences cannot be generalized to the large population of nurses and their experiences of clinical practice. Research was also contained to central Taiwan, so it may not be representative of other areas.
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