Objective: To explore the challenges of mental health nurses in dealing with psychiatric patients.
Method: The qualitative, descriptive, phenomenological study was conducted at three public and private psychiatric setups in Karachi from August 13 to October 30, 2018, and comprised mental health nurses having a minimum 6-month experience of working in a psychiatric ward. Data was collected using focus group discussion using a semi-structured interview guide. The proceedings were transcribed, translated and analysed using thematic analysis, leading to the formation of themes, categories and sub-categories.
Result: Of the 15 nurses with mean age 25±1.95 years, 5(33.3%) were from the public sector and 10(66.6%) were associated with private-sector institutions. Besides, 7(46.6%) nurses had work experience up to 5 years. There were three sessions of focus group discussion; 1(33.3%) of public-sector nurses and 2(66.6%) of priver-sector nurses. Each session had 5(33.3%) participants. Post-transcription feedback was provided by 8(53%) nurses. There were 4 themes; lack of resources, safety-related challenges, lack of staff capacity building, and lack of support. The themes overall had 14 categories and 7 sub-categories.
Conclusion: The nurses exposed to patient aggression should be provided debriefing sessions to deal with possible burnout.
Keywords: Career, Mental health nurses, Mental health, Public health, Stigmatised, Violence. (JPMA 73: 776; 2023)
Submission completion date: 21-12-2021 - Acceptance date: 10-11-2022
Mental health nursing is a specific field of the nursing profession. Nurses working in psychiatric settings need to provide high-quality care to patients in a difficult and challenging work atmosphere.1 Globally, nurses’ experiences in diverse clinical settings have attracted professional attention in recent years.2 However, in developing countries, not much literarture is available about the experiences of mental health nurses.3 Psychiatric problems are becoming an alarming public health concern around the world as the disabling and deliberating conditions associated with psychiatric illness lead to a less productive life.4 Individuals with mental health problems are more likely to suffer from other health-related issues, and their mortality rate is 4-7 fold higher.5 A newspaper report in 2016 stated that Pakistan had 50 million people suffering from psychiatric problems among whom 15-20 million were adults.6 At present 600 psychiatrists in Pakistan in both public and private sectors and 700 clinical psychologists are accessible in the country, but there are only 300 qualified psychiatric nurses.7
Nurses working in mental health settings encounter difficulties and challenges that impact their performance directly. They are misunderstood in public as well as among peers, and thus become stigmatised. Such challenges negatively affect their professional working. Mental health nurses have the highest probability of facing violence with psychological consequences, like stress, anxiety, and lower job satisfaction, as well as physical consequence, like injuries and short-term or long-lasting disability.8 A study in Ontario reported that about 8% mental health nurses had suffered injuries because of aggression and violence.9
This moral distress results in feelings of guilt, frustration and anger that are psychological and physiological mal-responses.10 Burnout has also been associated with mental health nursing which is generally known as one of the utmost challenging professions in terms of staffing and obligations.11 There is a lack of studies on the challenges faced by nurses in psychiatric settings12 even though the nurses in psychiatric settings work in exceptionally hectic and high-pressure settings.13 There has been no such study done in Pakistan. The current study was planned to fill the gap by exploring the challenges mental health nurses encounter in providing care to psychiatric patients.
Subjects and Methods
The qualitative, descriptive, phenomenological14-16 study was conducted at three public and private psychiatric setups in Karachi from August 13 to October 30, 2018. After approval from the institutional ethics review committee of Ziauddin University Karachi, the sample was raised using maximum variation sampling technique. Those included were mental health nurses having experience of working in a psychiatric ward for a minimum of 6 months and up to 50years and above.17 Informed consent was taken from all the subjects and those not willing to participate were excluded.
Data was collected using focus group discussion (FGD) sessions conducted with the help of a semi-structured interview guide to have insight of the participants.18 interview guide was pilot-tested on two individuals who were not part of the main study.
Open-ended questions were used to give opportunity to the participants to describe in detail their experiences. The questions included: What do you think about mental health services in Pakistan?; What are the most important obstacles facing nurses while delivering care to mental ill patients?; In your opinion how we can overcome to these barriers?; What are the challenges facing nurses while delivering care psychiatric patients?; What are the coping strategies if a problem arises?
Data saturation was achieved when no new information was available with the participants. Each FGD took 60 minutes. The sessions were audio-recorded. The contents were transcribed verbatim and the identity of the participants was code as alphabets. The transcribed version was checked for correctness.13 Noteworthy statements were noted, collective formal meanings were structured into groups of themes (coding), thorough descriptions were written. For the purpose of the study, Credibility meant confidence and trust in the study findings; Dependability meant the stability of the study data which is similar to reliability; Conformability meant maintaining neutrality in research to make the findings reliable, and Transferability meant the level to which the results were generalisable.19 For post-transcription feedback, the data was sent to all the participants. It was also sent to experts for external audit. Finally, Data was analysed using thematic analysis, leading to the formation of themes, categories and sub-categories.
Of the 15 nurses with mean age 25±1.95 years, 5(33.3%) were from the public sector and 10(66.6%) were associated with private-sector institutions. Besides, 7(46.6%) nurses had work experience up to 5 years. There were three sessions of focus group discussion; 1(33.3%) of public-sector nurses and 2(66.6%) of priver-sector nurses. Each session had 5(33.3%) participants. Post-transcription feedback was provided by 8(53%) nurses. There were 4 themes; lack of resources, safety-related challenges, lack of staff capacity building, and lack of support. The themes overall had 14 categories and 7 sub-categories (Table).
The first theme was lack of resources. The participants defined shortage of supplies as an unmet demand of the patients.
“Medication shortage is our big challenge because patients and attendants both come directly to the nursing station and ask for medicine, and sometimes if we are unable to provide medicine in time, then the patient suffers.”
The participants also talked about lack of intangible rewards for mental health nurses, like recognition and appreciation from the higher management.
“There is no encouragement and reward from the management to provide positive motivation for doing quality work, and it is a big tragedy that we have minimal support from them.”
Participants from both public and private sectors mentioned low salary and less motivation that ultimately decrease the quality of care.
“Salary packages are not good enough as nurses suffer from financial burden and this increases their stress level.”
“Psychologically, support from the management in the shape of rewards means a lot as it motivates us to deliver good performance and quality care.”
Scarcity of resources in terms of shortage of trained staff to deal with psychiatric patients was also mentioned by the participants.
“The big tragedy that we have is the lack of resources in terms of specialised trained staff when we encounter aggressive and violent patients, we don’t have enough skills to deal with such patients. Mostly we become victims of patient’s aggressive behaviour which causes harm physically and mentally to us.”
Participants from the public sector said that budget for mental health was much less than required due to which they were not able to provide efficient care to mental health patients. Therefore “There is a lack of funds in providing a good rehabilitation centre with full equipment required for it. Thus, it does not enable us to deliver better services to the patients.”
The second theme was safety-related challenges, which was sub-categorized into issues related to the safety of patients, nurses and environment.
“Patient safety is our utmost priority and it can be achieved through strong collaborative team and we can also enhance our communication skills which is a therapeutic cornerstone in mental illness, but unfortunately we do not do it.”
Patient safety had two types; conflict among patients, and self-harm. “The patients do self-harm when they have experienced physical, emotional, sexual or drug abuse crisis in their lives.”
The nurses emphasized that safety was very important to prevent workplace-induced injuries and harm. Nurses’ wellbeing is critical for vigilant monitoring of patients.
“It is not an easy task to work with mentally ill patients as I remember one year ago during my night duty, a maniac patient came to me and directly punched on my head and I became semi-conscious. He was continuously beating me. I was alone at the counter as no staff was available. The purpose of sharing this incident is to highlight that we are always at risk of having injury or harm which is a challenge for us regarding our safety.”
The elements of physical attack and aggression were highlighted by the nurses.
“When patients do physical attack, it makes us feel under threat. I remember in my last evening duty, a patient became aggressive and I was trying to calm her down, but unfortunately she attacked me and I dropped on my knees rather badly and I still have pain in my knees. I also got some other wounds and my shirt got torn.”
The participants endorsed the view. “When we interact with patients for the first time, the behaviour of the patient is really aggressive and this becomes a risk for us even to go to their bedside and interact with them as they indulge in direct violence and attack us.”
Addressing the needs of mentally ill patients’ safely is very important in psychiatric nursing practice, the subjects said. “When patients become aggressive they start to be violent. They either harm the staff or damage whatever things they come in contact with.”
The third theme was lack of staff capacity-building. The participants were of the opinion that they had fewer opportunities for capacity-to update their knowledge related to mental health services.
“It is mostly observed that in our system, our psychiatrists do not pay attention to the nurses. It is one of the misfortunes of our country that we are ignored by the government and also by the management which directly impacts our capacity-building.”
The lack of capacity-building was defined as fewer continuous nursing education (CNE) sessions. “Nurses should be provided with updated sessions on specific topics. Nurses should be aware through continuous education sessions by workshops, seminars and ward teaching.”
Clinical teaching by highly qualified professionals or psychiatrists creates more opportunities towards learning and dealing with patients. “When the psychiatrists do bedside rounds, they do not discuss the prognosis or condition of the patients with staff nurses. There must be sessions on bedside clinical teaching or in the conference room.”
Participants from the public sector described their challenges about lack of staff capacity-building in terms of skill building. “The higher management should provide chances to arrange sessions and encourage psychiatric nurses to attend outdoor sessions regarding the strategies to improve their skills.”
The fourth theme was lack of support. “There is no support for the psychiatric nurses from the organisation to motivate them even when they deal with patients in a crisis situation.”
The participants also shared their experiences regarding lack of support from the patients’ families. “The patient’s attendants’ behaviour is not cooperative at times. When the patient is in a private room and we are doing any procedure, the attendants do not cooperate and, in fact, they disturb us. Besides, they start to issue commands and order us around.”
“The management does not promote collaboration with nurses and psychiatrists to be on one platform as it is not the practice.”
Participants from the public sector expressed their views as well. “When the psychiatrists do bedside rounds and discuss the mental status of patients, they do not encourage the nurses to attend tutorials and post-round meetings.”
The participants also talked about the lack of support from family and community due to which the burden of work was increasing. “The family support for patients at home and at the community level is very bad. We mostly received patients with re-occurrence of mental disorder, whcih happens when patients get no attention from family, friends and the community.”
The current study is one of the first to focus on the challenges in the field of mental health nursing. The participants expressed a huge lack of resources, and the finding is consistent with earlier studies.20 Further, lack of specialised trained staff led to heavy workload. Nurses’ shortage in other areas has also been observed.21 Another study reported that nurses experience pressure created by inadequate resources, such as lack of staff, low salary and heavy workload.22 Additionally, finding specialised mental health nurses for recruitment is an ongoing challenge in the global health industry.23,24 The present study found that funds for mental health nursing practices were not good enough. Similar findings have been reported earlier.25,26
Likewise, safety-related challenges noted in the current study are in line with literature.27,28
Participants in the current study reported low level of capacity-building through CNE and clinical teaching. Participants also were of the opinon that educational content, teaching and CNEs were insufficient to empower a psychiatric nurse. This is in line with a study.29-31
The participants shared their concerns about the lack of patient and family support, lack of management support, lack of support from psychiatrists, and lack of community support for the nurses. The quality of working in mental health nursing is very low and it is observed that psychiatric services remain largely neglected. The shortcomings pointed out by the participants in the current study are in complete agreement with global literature.32-35
Nurses working at mental health ward and institutions reported weak areas in relation to providing care and management support to deal with professional shortcomings. The nurses exposed to patient aggression should be provided debriefing sessions to deal with possible burnout.
Acknowledgement: We are grateful to Ms. Alia Nasir and Ms. Amber Hussain for their guidance and support.
Conflict of Interest: None.
Source of Funding: None.
1. Zarea K, Fereidooni-Moghadam M, Baraz S, Tahery N. Challenges Encountered by Nurses Working in Acute Psychaitric Wards: A Qualiatative Study in Iran. Issues Ment Health Nurs 2018; 39: 244-50.
2. Zarea K, Nikbakht-Nasrabadi A, Abbaszadeh A, Mohammadpour A. Facing the challenges and building solutions in clinical psychiatric nursing in Iran: a qualitative study. Issues Ment Health Nurs 2012; 33: 697-706.
3. Ngako JK, Rensburg ESJV, Mataboge SML. Psychiatric nurse practitioners' experiences of working with mental health care users presenting with acute symptoms. Curationis 2012; 35: 44.
4. Lyons Z, Janca A. Impact of a psychiatry clerkship on stigma, attitudes towards psychiatry, and psychiatry as a career choice. BMC Med Educ 2015; 15: 34.
5. Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms--a qualitative study. PLoS One 2014; 9: e111682.
6. Staff Reporter. 50m Pakistanis Suffering from Mental Disorders. DAWN. 2016 October;9.
7. Qasim M. RMU Launching Psychiatric, Mental Health Nursing Pprogramme. International The News. 2019 January; 3.
8. Sabella D, Fay-Hillier T. Challenges in mental health nursing: current opinion. Nursing: Research and Reviews 2014; 4: 1-6.
9. Lantta T, Antilla M, Kontio R, Adams CE, Valimaki M. Violent events, ward climate and ideas for violence prevention among nurses in psychiatric wards: a focus group study. Int J Ment Health Syst 2016; 10: 27.
10. Weidema FC, Molevijl BAC, Kamsteeg F, Widdershoven GAM. Aims and harvest of moral case deliberation. Nurs Ethics 2013; 20: 617-31.
11. Tsaras K, Daglas A, Mitsi D, Papathanasiou IV, Tzavella F, Zyga S, et al. A cross-sectional study for the impact of coping strategies on mental health disorders among psychiatric nurses. Health Psychol Res 2018; 6: 7466.
12. Chambers M, Kantaris X, Guise V, Valimaki M. Managing and caring for distressed and disturbed service users: the thoughts and feelings experienced by a sample of English mental health nurses. J Psychiatr Ment Health Nurs 2015; 22: 289-97.
13. Sobekwa ZC, Arunachallam S. Experiences of nurses caring for mental health care users in an acute admission unit at a psychiatric hospital in the Western Cape Province. Curationis 2015; 38: 1509.
14. Polit DF, Beck CT. Nursing Research: Gathering and Assessing Evidence for Nursing Practice. 9th ed. New Dehli: Wolters Kluwer; 2012.
15. Houser J. Nursing Research: Reading, Using and Creating Evidence. 4th ed. USA: Navigate; 2018.
16. Polit DF, Beck CT. Essentials of Nursing Research: Appraisng Evidence for Nursing Practice. 9th ed. Philadelphia: Wolters Kluwer; 2018.
17. American Psychaitric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington DC: American Psychiatric Association; 2013.
18. LoBiondo-Wood G, Haber J. Nursing Research-E-Book: Methods and Critical Appraisal for Evidence-Based Practice. 9th ed. China: Elsevier Health Sciences; 2017.
19. Lynne MC. Trustworthiness in Qualitative Research. Medsurg Nurs 2016; 25: 435-6.
20. Joubert PD, Bhagwanb R. An empirical study of the challenging roles of psychiatric nurses at in-patient psychiatric facilities and its implications for nursing education. Int J Africa Nurs Sci 2018; 9: 49-56.
21. Lee ES, Ryu V, Lee JH, Hong H, Han H, Park S. Psychometric Properties of the Korean Version of the Mental Health Professionals Stress Scale. Front Psychiatry 2021; 12: 685423.
22. Conradie M, Erwee D, Serfontein I, Visser M, Calitz FJ, Joubert G. A profile of perceived stress factors among nursing staff working with intellectually disabled in-patients at the Free State Psychiatric Complex, South Africa. Curationis 2017; 40: e1-e8.
23. Slemon A, Jenkins E, Bungay V Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Nurs Inq 2017; 24: e12199.
24. Ngako KJ, Van Rensburg ES, Mataboge SM. Psychiatric nurse practitioners' experiences of working with mental health care users presenting with acute symptoms. Curationis 2012; 35: 44.
25. Marie M, Hannigan B, Jones A. Challenges for nurses who work in community mental health centres in the West Bank, Palestine. Int J Ment Health Syst 2017; 11: 3.
26. Badu E, O’Brien AP, Mitchell R. An integrative review of potential enablers and barriers to accessing mental health services in Ghana. Health Research Policy and Systems 2018; 16: 110.
27. Alhassan RK, Poku KA. Experiences of frontline nursing staff on workplace safety and occupational health hazardsin two psychiatric hospitals in Ghana. BMC Public Health 2018; 18: 701.
28. Bimenyimana E, Poggenpoel M, Temane A, Myburgh C. A model for the facilitation of effective management of aggression experienced by Psychiatric Nurses from patients in a psychiatric institution. Curationis 2016; 39: e1-e9
29. Smith M, Khanlou N. An Analysis of Canadian Psychiatric Mental Health Nursing through the Junctures of History, Gender, Nursing Education, and Quality of Work Life in Ontario, Manitoba, Alberta, and Saskatchewan. ISRN Nurs 2013; 2013: 184024.
30. Moghadam MF, Khoshknab MF, Pazargadi M. Perceptions about Physical Restraint; A Qualitative Study. Int J Community Based Nurs Midwifery 2014; 2: 20-30.
31. Bressington D, Badnapurkar A, Inoue S, Ma HY, Chien WT, Nelson D, et al. Physical Health Care for People with Severe Mental Illness: the Attitudes, Practices, and Training Needs of Nurses in Three Asian Countries. Int J Environ Res Public Health 2018; 15: 343.
32. Hylén U, Kjellin L, Pelto-Piri V, Warg LE. Psychosocial Work Environment within Psychiatric Inpatient Care in Sweden: Violence, Stress, and Value Incongruence among Nursing Staff. Int J Mental Health Nursing 2017; 27: 1086-98.
33. Knaak S, Karpa J, Robinson R, Bradley L. They are Us-We are Them": Transformative learning through nursing education leadership. Healthc Manage Forum 2016; 29: 116-20.
34. Tofthagen R, Talseth AG, Fagerström L. Mental health nurses' experiences of caring for patientssuffering from self-harm. Nurs Res Pract. 2014; 2014: 905741
35. Hanafiah AN, Bortel TV. A Qualitative Exploration of the Perspectives of Mental Health Professionals on Stigma and Discrimination of Mental Illness in Malaysia. Int. J. Ment. Health Syst. 2015; 9: 10 DOI:https:\doi.org\10-1186\s\3033-015-0002-1.