Abstract
BACKGROUND:
Nursing is a dynamic and supportive job, with the main role of taking care of patients. Maintaining appropriate communication of the nurse with the patients is particularly known as the main core of care in mental health. However, in spite of the importance of providing communication, one of the main sources of stress in nurses of psychiatry wards is communication with the patients. Some important reasons for inappropriate relationship between the nurse and patient can be lack of necessary skills to communicate with patients because of insufficient training. Although training communication skills is an important part of the education of medical and paramedical students, in recent studies it has been demonstrated that the communication skills learned in theoretical courses would not necessarily be transferred to clinical settings, and proving training in clinical settings is a must. The present study was carried out to determine the effect of training communication skills using psychoeducation method on the stress level of nurses of psychiatry wards in 2010.
METHODS:
This is a quasi-experimental study. The participants were 45 nurses; 23 and 22 in the experiment and control groups, respectively, working in psychiatry wards of Noor and Farabi hospitals, Isfahan, Iran. The sampling was carried out by the census method, and then the participants were randomly assigned to the two groups of experiment and control, using random number table. The two groups filled out the demographic data form and also the questionnaire on nurses’ occupational stress, designed by the researcher. The questionnaire was filled out three times; before, immediately after, and one month after the training. Training of communication skills was carried out using group psychoeducation method, in six sessions, each lasted for 1.5 hours. The training sessions of the experiment group were held in Farabi Hospital.
RESULTS:
The findings indicated that before the intervention, the members of the two groups had a high level of occupational stress. Immediately after the training, the stress level of the experiment group decreased significantly, and the decrease was sustained for the following one month.
CONCLUSIONS:
Training communicative skills using group psychoeducation method can decrease the occupational stress of psychiatry ward nurses.
Keywords: Communicative skills, group psychoeducation, psychiatry ward nurses
Nursing is a dynamic and supportive job, with the main role of caring for patients. Through communicating with patients, nurses become aware of the feelings, needs, and problems of the patients, and can take care of and treat the patients. The ability to communicate patients is one of the professional requirements of nursing, and being aware of the communicative skills is one of the characteristics of clinical competence of a nurse.1
However, providing an appropriate relationship between the nurse and patient is particularly the core of care in mental health,2 and one of the critical responsibilities of nurses in psychiatry wards is to provide appropriate communication with the patients.3 Providing appropriate communication with the patients is one of the necessary tools for nurses in psychiatry wards, which is useful in management of the patients with psychiatric disorders.4 In a study on the factors effective on communication of the nurses with the hospitalized psychiatric patients, it was demonstrated that the ability to understand the patient, empathy with him/her, and appropriately communicate with him/her has a deep effect on the bilateral relationship of nurses and patients in emergency psychiatry wards.5
In spite of the importance of proving treatment relationship, this is one of the known sources of occupational stress in psychiatry ward nurses.6 Pompili et al stated that although all nurses receive the same sources of stress, there are some particular requirements in psychiatry wards, including the normal interaction with the patients hospitalized in these wards.7 In different studies, it has been demonstrated that because of the particular nature of nursing, the job is susceptible to high levels of stress, and because of the particular situation of the patients in psychiatry wards, working in these wards is accompanied with higher levels of stress.8
The unique circumstances in psychiatry wards and situational emergencies are the main sources of stress in nurses of these wards. These nurses are working with the group of patients, who can always make a crisis. These crises can be escape, suicide, and aggression, which make a stressful environment for the nurses.9 The main reasons of psychological and physical harms of the psychiatry ward nurses are aggression, delusion of control, and paranoia of psychiatric patients, which may result in leaving the job by nurses.10
Fakhoury and Wright (2008) carried out various studies on physical harms of the therapists working in psychiatry centers, and stated that the nurses who have lower scientific and professional competence and do not have adequate knowledge about how to deal with and provide an appropriate relationship with psychiatric patients are more susceptible.11
An important reason of inappropriate nurse-patient communication is the insufficient skill of the nurse in providing the relationship, because of the inadequate education.12 Although communication skill training is an important part of education in medicine and para-medicine fields, it was demonstrated that the theoretical communication skills cannot necessarily be used in clinical settings, and education in clinical fields is also necessary.13
In this regard, group psychoeducation have increased the satisfaction of the trainees, as well as profitability of the health clinics. Since the main goal of this method is encouragement of the trainees to enhance their knowledge and improve their skills in different fields, the method has been accepted through the world, and the trainees with insufficient skills have benefited from the training. Furthermore, since the most common type of group psychoeducation is focusing on the problem, providing necessary information about the problem, and how to cope with the problem, and dealing with subsidiary tasks is avoided, it is the most suitable education method for skill requirements of the nurses.14 By applying group psychoeducation program, psychiatric nurses can help the nurses achieve a more extensive understanding of the problems and also to enhance their skills in identifying and using the problem coping strategies.15
Therefore, considering what was mentioned above, and also the concerns about improvement of the quality of communication skills of nurses, and also with regard to the importance of improvement of nurses’ communication skills, and the few studies in this regard,13 it was feasible to carry out the current study.
Method
This is a quasi-experimental study. The data was gathered in the two groups of experiment and control, before, immediately after, and one month after the education. Thus, study was a multivariate one, performed in three stages. The study was carried out in Noor and Farabi Hospitals, affiliated with Isfahan University of Medical Sciences, both of which have active psychiatry wards. The population under study was all male and female nurses with B. Sc. of nursing, who meet the inclusion criteria and exclusively work in emergency or acute, chronic, or specialized men and women wards of psychiatry in the two hospitals.
Sampling method was census method, in which at the first step, all nursing personnel who had B. Sc. of nursing entered the study. Then, the objectives of the study were explained for them, and if they were willing to participate in the study, they were asked about their major stresses during the past 12 months, according to Holms and Rahe stress scale. Then, the nurses who obtained scores below 150, and met the inclusion criteria, attended the study. At the end of the sampling process, a questionnaire on the demographic information of patients and also a questionnaire designed by the researcher about the occupational stress of nurses in psychiatry wards were given to the participants.
Nineteen nurses worked in the Noor Hospital psychiatry wards, out of whom four refused to participate the study, one worked in another ward also, and one obtained score higher than 150 in the Holms and Rahe stress scale. Thus, the number of participants from Noor hospital was 14.
The number of nursing personnel in the psychiatry wards of Farabi Hospital was 60, out of whom ten nurses had filled out the questionnaire previously to verify the reliability of the questionnaire designed by the researcher, and thus were excluded from the study. One was off during the study, 15 worked in other wards also, two were not willing to attend the study, and two obtained score higher than 150 in the Holms and Rahe stress scale. Therefore, the number of participants from the Farabi Hospital was 31. The total number of participants in the first step of the study was 45.
In the second step, the participants were randomly assigned to two groups; experiment and control. According to the random number table, of the 23 participants in the experiment group, four (17.4%) and 19 (82.6%) were from Noor and Farabi hospitals, respectively, while of the 22 participants in the control group, 10 (45.5%) and 12 (54.5%) were from Noor and Farabi hospitals, respectively.
The data was collected using a questionnaire on the demographic information of the participants and a questionnaire designed by the researcher to measure the occupational stress of nurses in psychiatry wards. The questionnaire designed by the researcher was based upon Tuft-Anderson's questionnaire, psychiatric nurses occupational stress scale (PNOSS), and also opinion poll of some nurses working in psychiatry wards about the sources of their stress. To determine the validity of the questionnaire designed by the researcher, it was revised and approved by five faculty members of psychiatric nursing, one PhD of nursing, three psychiatric nurses, two psychiatrists, and six psychologists. Moreover, to determine the reliability of the questionnaire, it was given to ten nurses working in psychiatry wards. Finally, using the alpha Cronbach coefficient, the reliability of the questionnaire was determined to be 0.954.
The questionnaire consisted of 34 questions, on a four point scale, ranging from 0 to 3, in which 0 implied no stress, 1 mild stress, 2 moderate stress, and 3 high stress. Thus, the highest and the lowest possible scores of the questionnaire were 102 and zero, respectively. The questionnaire covered six fields; nine items on coping with threatening cases, four items on shortage of resources, nine items on personnel conflicts, five items on planning issues, four items on working load, and three items on unpreparedness for the occupational stress of psychiatric wards. Obtaining scores equal to or less than 30 was interpreted as low stress, while stress score of 40-62, and 63 and above indicated moderate and high stress, respectively. After case selection, six group psychoeducation sessions were held in three weeks for the experiment group, and the control group did not receive any intervention.
Using different educational models and by concentrating on improvement of communication skills of nurses in developing relationship with patients of psychiatry wards, the group psychoeducation sessions were held. The education models were delivering lecture, problem solving, brain storming, sharing the experiences of the members and discussion, and using different education tools such as personal computer and whiteboard.
After finishing the educational sessions, the educational leaflet of communication skills were given to the experiment group members. The researcher-designed questionnaire on occupational stress of the nurses working in psychiatry wards was given to the members of the experiment and control groups immediately after and one month after the educational sessions. Furthermore, after the third step of the experiment, the educational leaflet of communication skills was given to the members of the control group, as well.
The questionnaire data was extracted and analyzed using SPSS software, version 18, and by independent t-test and ANOVA with repetition of the observations.
Results
Out of the 45 participants of the study (23 and 22 participants in the experiment and control groups, respectively), 77.8% were female, and 66.7% of the participants were married. Most of them were on rotating shifts (73.3%), and most were in the age range of 25-30 (55.4%). Considering the results of the statistical tests, the two groups were not significantly different in terms of the demographic data.
The results indicated that the mean stress score before the intervention was 63.3 and 63.2 for the experiment and control groups, respectively, which was categorized as the high stress level, and the two groups were not significantly different in this respect. Immediately after the intervention, the mean stress score of the experiment group was significantly lower than that in the control group (54.9 versus 63.9) (p = 0.04). Moreover, one month after the intervention, according to the results obtained by independent t-test, the mean stress score was significantly lower in the experiment group (54.8 versus 64.3) (p = 0.03).
Analysis of the mean stress score before, immediately after, and one month after the intervention using ANOVA with repetition of observations demonstrated that in the experiment group, the stress scores obtained immediately after and one month after the intervention were significantly lower than that obtained before the intervention (p< 0.001). Furthermore, the means of stress scores of the experiment group immediately after and one month after the intervention were not significantly different (p = 0.88). However, the stress score of the control group did not significantly change immediately after and one month after the experiment, compared with the score obtained before the intervention (p = 0.87).
Discussion
In the study carried out to determine the stress level of psychiatry ward nurses using the summarized questionnaire of occupational stress, McGrath and Reid reported that psychiatry ward nurses experience high levels of stress. Moreover, they demonstrated that communicating with the patients is a main source of stress in these nurses. The working environment of the nurses is known to be potentially stressing, and it seems that the crowded environment of psychiatry wards has led to desensitization of the nurses to the inter-personal relationship with the patients.6 This is while in many cases, lack of skills in developing a communication with others is the source of stress. Sometimes, communicating with others will lead to misunderstanding and stress.16
According to Farber, communicating skills are a type of accommodation skill, which can modify the occupational stress.17 Mullan and Kothe carried out a study to evaluate the effect of education of first year nursing student about communication skills on their satisfaction and self-actualization. In the study, 209 nursing student completed the program, and the results demonstrated that compared with the state before the intervention, after the course the students’ satisfaction and self-actualization with studying nursing has increased.18
The results of the study carried out by Bravo-Mehmedbasic et al to determine the effect of psychoeducation program on decreasing occupational stress of Sarajevo police staff demonstrated that a statistically significant decrease in the occupational stress and a positive increase in accommodation skills and communication skills occurred after the intervention. Moreover, the study indicates that in jobs, in which the employees experience long-term stresses, this method can be helpful. Psychoeducation can have positive effects on reducing the occupational stress.19
Delvaux et al evaluated the effectiveness of educational workshop of communication skills on the stress level of nurses working in oncology wards, and reported that the experiment group nurses have used facilitating behaviors in communication more frequently. Moreover, a significant decrease was observed in the use of communication barriers. They also measured the stress level of these nurses using nurses’ occupational stress questionnaire. It was shown that the communication skills and stress of the experiment and control groups were not significantly different prior the intervention. Nevertheless, the results of effectiveness of education three and six months after the intervention showed a considerable decrease in the stress level of participants of the experiment group, while the stress level did not change in the control group.20
Edwards et al evaluated the improvement of communication skills of nurses in the south region of Ontario before and five months after the intervention. It was shown that, five months after the intervention, a significant increase in employment of communication skills by the nurses, and the score of quality of employing communication skills increased from 2.4 to 2.68 (p = 0.001).12
Chao carried out a study on applying group psychoeducation in Taiwan, and stated that application of the program improved knowledge, attitude, and self-effectiveness of nurses who provide care to the elderly immediately after and three months after the group psychoeducation program.21
The results obtained by statistical analysis of the data indicated that teaching communication skills using group psychoeducation method can decrease the stress level of nurses in psychiatry wards, and the decrease was sustained one month after the training. Considering this finding, it is necessary to improve the communication skills of nurses in their working environment; particularly for the nurses working in psychiatry wards, who encounter specific types of occupational stress.
Moreover, considering the necessity of communication skills of nurses to decrease their stress and increase their mental health, as well as to prevent the costs of occupational stress complications, educational in-service courses should be held each 12 months to emphasis the communication skills of nurses.
With regard to the sensitivities of the nursing job, including communicating with and taking care of the patients, ignoring the identification of these stresses and not avoiding them will lead to different complications. On the other hand, considering the responsibility of taking care of the patients, stresses of the nurses would affect organizational efficiency. With respect to the results of the study, nursing and hospital managers can pay more attention to the factors that lead to disturbance of nurses’ mental health. Moreover, the managers can minimize the occupational stress and thus decrease occupational exhaustion of the nurses by providing an appropriate working environment and being a model for the nurses working in the wards, supervising the communications of nurses with the patients, and proving the background to lowering the work load of the personnel to give them more opportunity to communicate with the patients.
Considering the results, the nurses working in psychiatry wards can take the advantage of developing an appropriate communication with the patients as a method of accommodation with their occupational stress. Based on the findings, it is advisable to consider development of appropriate communication with the patients as one of the nursing responsibilities, and note it even in the nursing reports. Using communication skill education, the nurses would become more aware of their misconducts in interactions with the patients, and would try to improve this essential nursing skill and their mental health.
The authors declare no conflict of interest in this study.
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