Abstract
BACKGROUND:
Psychiatric team plays an important role in treating and taking care of psychiatric patients. Using this team's experience seems necessary for enhancing care services. The aim of this study was to assess psychiatric team's experience of working in different psychiatric groups.
METHODS:
This is a qualitative study with phenomenological approach. Samples were chosen using purposive sampling method. Samples included 10 personnel from psychiatric wards of 4 hospitals in Isfahan city in 2007. Data was gathered using deep interviews which were recorded on tapes. Data was analyzed using Colaizzi's seven steps method.
RESULTS:
Results from participants’ experiences were summarized in 3 main concepts: “communication”, “ability” and “conflict”; and 5 sub concepts: “cooperation”, “self acknowledgement”, “hope”, “qualification” and “multiple roles”.
CONCLUSIONS:
Results of this study could be used in future programming to enhance care services for psychiatric patients in hospitals.
KEY WORDS: life experiences, qualitative research, hospital psychiatric department, Psychiatric nursing
In the past, each psychological personnel treated their psychic patient in their own way and based on their specialty, each one tried to help the patient. Even sometimes their work was in conflict with others and could be confusing for the patient. This attitude led to chaos and incomplete care of patients.1
Since most mental patients require hospitalization and a comprehensive treatment system, a care team consisting of different specialists gather up to find the best method for treating the patient.
Psychiatric team includes a psychiatrist, psychologist, psychiatric nurse, social service worker, work therapist, entertainment therapist and rehabilitation specialist. Each one plays an important and multiple role and they take care of the patient to adapt with the situation and gain back his abilities based on their skills, techniques and council principles during care and medical interventions. Psychiatric team's members need to communicate with other members to gain more success in their job and this requires continuous care and cooperative efforts with other members of the team.2
Different treatment approaches toward mental patient leads to formation of special teams, whether in institutes or in social groups, which allows the psychiatric team to be involved in patient's treatment and society's approaches.3
Vidbeck believed that improvement of team functioning in psychiatric ward depends on intra personal skills like patience, tolerance, understanding, intuition, humanity, kindness, acceptance, charity, knowledge and awareness about signs and behaviors caused by mental disorders, communicational skills and work skills of the team like cooperation and shaing.4
Since effective psychology and psychiatric nursing approach is based on hope and optimism and this belief that all the patients, even chronic mental patients whose functioning is completely destroyed, can change and enhance, so it's possible to help a patient improve by knowing their abilities and empowering them. Generally people think that mental disorder is an incurable and progressive problem. Usually these assumptions make the patient, their families and health care team's members disappointed and makes them to concentrate on protecting the current functioning of the patient.5
It is obvious that psychiatric ward's personnel learn special skills during team work and cooperating with each other which makes them more hopeful to the results of treatment. They can reach the satisfying feeling of self acknowledge by searching for their thoughts and feelings. Also self acknowledgement can be a good motivation to find out about their mental disorders like confusion, anxiety and depression.6
Psychiatric team can discover their strengths and weaknesses during understanding their thoughts, feelings and intuitions and this leads them to find more effective medical interventions. So expressing their feelings and experiences regarding team work in psychiatric groups seems to be very important and necessary.7
Since the subject of this study is human experiences, descriptive phenomenological method is used to explore behaviors, feelings and experiences of psychiatric team's members based on the depth of their experiences, and its aim is to understand the main structure of human experiences. Discovering this team's feelings and intuitions can be an important tool to evaluate and measure their reactions and responses to different situations and environmental phenomena. This can help health care authorities to have more knowledge, experience and skill to improve the quality of treatment, rehabilitation and caring for mental patients. Team work in psychiatric wards can present a new viewpoint toward mental patients which leads to more useful and effective methods for their treatment.
Methods
Personnel from different psychiatric wards like psychiatric emergency and acute, chronic and special psychiatric ward were enrolled in this study. Inclusion criteria included knowledge about the aim of the study, ability to participate in the interviews and share the feelings and information. Exclusion criterion was having any significant physical or mental disorder which could affect the interview process.
Considering the geographic positions of centers, the ability to admit patients (having medical equipments and enough personnel and beds) and also availability of psychiatric emergency and acute, chronic or special psychiatric wards for women, men, kids and elderly, Farabi, Noor, Al-Zahra and Shahid Modarres hospitals were selected as the statistical society.
Since information from situations or phenomena are more important than the samples size in qualitative studies, 2 samples from Farabi hospital, 4 from Noor hospital, 2 from Al-Zahra hospital and 2 from Shahid Modarres hospital were selected. Deep interviews were used to gather information. Length of the Interviews varied from 30 to 90 minutes, based on physical and mental condition, how busy the participant is and his tendency toward talking. In each interview participants were asked about their experience of team working in psychiatric wards and based on their answers next questions were asked. After interviews, the researcher listened to recorded tapes to see if the content is understandable or it needs follow up and if there are any other issues that must be asked during further interviews. Then the recorded tape was listened to very carefully and transformed into written form. After writing down the interviews, they were coded and analyzed. After categorizing codes and emerging related codes, all of them were categorized in 3 main concepts.
Accuracy and strength of a qualitative study is dependent on accuracy and comprehension of gathered information. In this study validity means every recorded case have really been happened and reliability means similarity between information explanations and recorded cases.8 This study tried to have four criteria for reliability of qualitative information and their analysis which are being believable, ensure accountability, being affirmable and being sharable. The researcher tried to avoid any kind of siding during data gathering process. The aim of this study was to improve accuracy and strength of data and transfer them to other situations or other teams in other psychiatric wards and hospitals. Also gender, age range, job experience and experience of working in different psychiatric wards were varied among participants. It must be mentioned that to make data reliable, researcher referred to participants’ interviews many times after categorizing. Also for validity, after categorizing the data, they were referred to participants to get their final approval and discuss important issues. Colaizzi's seven step method was used to analyze the data.
Results
In the first step of Colaizzi's analyzing method, recorded statements of participants were listened to very carefully, then transferred to written type and were reviewed carefully many times.
In the second step, written statements were reviewed and significant and important lines and sayings were marked. In the third step researcher tried to relate a specific concept to each important line. In the fourth step, researcher repeated the third step for each descriptor and then common concepts were classified into thematic categories. It must be mentioned that to validate the data, researcher referred to participants’ statements many times after categorizing.
In the fifth step all of the extracted beliefs and concepts were merged into one whole and comprehensive description which included all of the under studied details and in the sixth step, the phenomenon was summarized into one brief real description.
In the final step, researcher referred to participants again to validate and clarify the result of the study.
For example, participants mentioned positive and creative consequences of working in psychiatric wards (like self acknowledgement, self control, stress management …) besides studying their own feelings and experiences. They believed that one of the positive aspects of working in this environment is to gain a self controlling feeling and practice that feeling in work place, and they were even proud of themselves for using these feelings, experiences and knowledge outside work and especially in their homes. Participant number 5 stated that:
“After working in this ward I realize how patient I am and I can tolerate all of my patients and coworkers.” So codes like patience, tolerance, satisfaction, confidence … were extracted and then after comparing and merging some of the concepts from “self control”, “satisfaction”, “adaptation” and “cognition” sub categories, the main sub concept of “self acknowledgement” was formed. Also after comparing and merging some of the concepts from “knowledge”, “efficiency”, “learning” and “job skills” sub categories, the main sub concept of “qualification” was formed. These two formed the main concept of “ability” and based on 7 steps of Colaizzi's method, all 3 main concepts were formed.
Results of participants’ experiences were finally summarized in 3 main concepts of “communication”, “ability” and “conflict” and 5 sub concepts of “cooperation”, “self acknowledgement”, “hope”, “qualification” and “multiple roles”.
Discussion
Since humans are social creatures that need to have communication with others, they start their communication by exchanging feelings, aspects and motivations and satisfy their physical and mental needs in this way.9
Considering that treatment and care for mental patients needs teamwork, the relation between the members is of high importance. Team activity is impossible without the presence of the relations. This relation must necessarily be constructive and goal-oriented
Members of the psychiatric team need to learn communicational and cooperative skills during work, besides learning how to have proper communication with their patients, which can lead to expected consequences and goals of treatments. Cooperation between team members makes them learn better about the patient's needs and find a more effective treatment for them.
To have a good team working, members of team can solve communicational issues among team members by avoiding distortion, doing things again and individually and trying to help the patient as much as possible; they are co-workers, working on a problematic issue and they all have one goal. Cooperation ensures team's improvement toward the main goal.11 Psychiatric team gains some special skills during working together. When a patient shows aggressive and uncontrollable behaviors, psychiatric personnel not only can control the situation by empowering self controlling skill, without showing any improper judgment and punishments, but they also can control their feelings and functioning too. This self controlling skill can be role model for other members and patient and teach them how to control themselves in different situations.12
Information gathered from participants’ statements showed that working in psychiatric ward can motivate all of the members to discover feelings, intuitions and subjective interpretations of themselves and even their co-workers and lead them to self knowledge which affects the functioning of the whole system. This scale as an effective method can enhance the fundamental quality of psychiatric institute and make the team members more hopeful about the results of treatments hence the team would be empowered. Results of the present study confirm the results of Demarco et al study regarding self acknowledge and hope. So based on what was mentioned above and similar experiences it could be concluded that controlling and managing the environment and also taking care of these special patients in psychiatric wards can lead to multiple roles which weakens the relation between team members.
In regard to this topic, the participant No. 7 says: “If at least once a month, a meeting could be held among the staff of this ward (enrolling pschologists, matrons, psychiatrists and all the nurses), we could have solved some of our issues and problems. In my work shift, I may not let my patient to smoke, contrary to that, my fellow may let him/her to do so. Besides, the psychiatrist may react another way…”.
Based on the cited statements mentioned above and some similar experiences, we can realize that although all the members of the psychiatric team are following one subject and their purpose is to achieve a final destination and a common goal, the differences between their methods, practices and point of views may cause conflict and disagreement among them. This is not only destructive but can also spontaneously improve the quality of the care and treatment.
Any conflict and disagreement between the staff of each workplace and organization is not something unusual and abnormal. Sometimes, this can lead to slow work, but it can be useful and effective too.13
Disagreement among the healers (particularly in group and teamwork professions such as psychiatry) is inevitable and natural. The views and perspectives of people are different depending on their assignment and experiences. For instance, transmission of a patient from a ward to another unit has always been a kind of professional discussion and debate between the team of psychiatry. This has been mentioned in the statements of the participant No. 4 : “I′ve learned lots of things from the matron of our ward; he/she is an experienced person and knows what to do exactly, he/she has been working here for a long time. But sometimes, we disagree on a treatment and care issue and finally we can learn some experience from each other”.
Ansinares and Pollen stated that growth and improvement of nurses and their theoretical and practical skills and cooperative learning are due to the consequences of these contradictions.14
Teamwork has some benefits such as strengthening the relations, coordination between the methods, making a comprehensive care and a comprehensive support for the patient. Due to lack of effective and constructive coordination between the team members, some consequences and challenges would occur between them such as role distribution issues, contradictory behaviors with the patient and conflict among the staff.
It could be understood from the participants’ statements that there are psychiatric teams in our mental hospitals but they don′t work as a team. Different cultures of team members and not being familiar with each other's roles and responsibilities pose an important obstacle toward team work which could be solved gradually through teaching, changing their aspects and exercising team work.
Since treating mental patients is a team work, the relation between team members is very important. Team work is impossible without relationship. These relations must be constructive and purposive. Team work culture is not adapted in many psychiatric centers in the world yet which is completely obvious in Jevis's study. He has mentioned that psychiatric personnel are not taught to work in a team and can′t cooperate with each other to treat patients. They need education to make their team work effectively and to manage patient's critical situations.13
It is obvious that there are specific responsibilities for each member in a team. When one member's responsibility is dependent on another one's job, they all would be dependent on each other and lack of coordination between them would lead to conflict and opposition.14
It is obvious that based on individual thoughts and beliefs, there might be some conflicts among team members and this is not an uncommon thing. Team members always face conflicts whether they work on designing and programming or on execution. Although these conflict can slow down the process, but based on participants’ statements they can be really useful and constructing sometimes and can solve problems, empower and improve the patient's metal situation and correct the behaviors of patients and team members. The consequences of conflict among multidimensional psychiatric team members are dynamic and effective relations, sharing experiences and improving skills and in the end, enhancing job safety and quality of given services.15
Results of this study can help all the psychiatric personnel to better understand themselves and learn about their strengths and weaknesses and try to find better ways for improving team work.
The authors declare no conflict of interest in this study.
Acknowledgments
We thank all the coworkers and personnel who helped us gather the data and try improving team work in psychiatric wards.
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