Issues in Mental Health Nursing ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20 Challenges Encountered by Nurses Working in Acute Psychiatric Wards: A Qualitative Study in Iran Koroush Zarea, Malek Fereidooni-Moghadam, Shahram Baraz & Noorollah Tahery To cite this article: Koroush Zarea, Malek Fereidooni-Moghadam, Shahram Baraz & Noorollah Tahery (2017): Challenges Encountered by Nurses Working in Acute Psychiatric Wards: A Qualitative Study in Iran, Issues in Mental Health Nursing, DOI: 10.1080/01612840.2017.1377327 To link to this article: http://dx.doi.org/10.1080/01612840.2017.1377327 Published online: 24 Oct 2017. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imhn20 Download by: [University of Florida] Date: 25 October 2017, At: 03:39 ISSUES IN MENTAL HEALTH NURSING https://doi.org/./.. Challenges Encountered by Nurses Working in Acute Psychiatric Wards: A Qualitative Study in Iran Koroush Zarea, PhDa , Malek Fereidooni-Moghadam, PhDb , Shahram Baraz, PhDa , and Noorollah Tahery, PhD Studentc a Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; b Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran; c Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran Downloaded by [University of Florida] at 03:39 25 October 2017 ABSTRACT Background: The provision of care to patients with psychiatric disorders and working in a challenging environment lead to many problems among psychiatric nurses. The aim of this study was to explore the challenges nurses faced while working in acute psychiatric wards. Design: A qualitative design using content analysis was used. Fifteen nurses working in psychiatric wards in hospitals affiliated to a university hospital in an urban area of Iran were chosen using a purposive sampling approach. Semi-structured interviews were used for data collection. An inductive content analysis method was used to analyse the collected data. Results: Four themes were developed based on the analysed data: “experiencing psycho-social challenges,” “experiencing psychological challenges,” “encountering catalysts causing challenges,” and “employing various strategies for coping with challenges.” Conclusions: Given the importance of physical and mental wellbeing of nurses and the moral and professional responsibility of an organization to protect staff health, it is of prime importance to examine the inpatient psychiatric nurses’ experiences to better understand them and hopefully use such knowledge so as to improve their work life. Introduction Psychiatric nursing is a specialized field of nursing practice that focuses on the provision of care to patients with mental disorders (Barker, 2009; Humble & Cross, 2010). Nurses working in acute psychiatric care units need to deliver high quality care to patients in a complex and challenging work environment (Chambers, Kantaris, Guise, & Valimaki, 2015; Moghadam, Pazargadi, & Khoshknab, 2013). Therefore, providing care in such an environment is associated with some challenges and stress. A plethora of studies have considered psychiatric nursing as a stressful profession (Abdalrahim, 2013; McGrath, Reid, & Boore, 2003; Ward, 2011). In a study conducted by Carson, Leary, de Villiers, Fagin, and Radmall (1995), it was revealed that psychiatric nurses experienced significantly high levels of work stress. Despite the fact that psychiatric nursing has various similarities to other nursing specialties, it is different because staff members have deeper relationships with their patients, attempt to put a stop to self-harm, and regularly come across challenging behaviours in the environment (Dallender, Nolan, Soares, Thomsen, & Arnetz, 1999; Jenkins & Elliott, 2004). Also, patients with psychiatric disorders admitted to acute inpatient settings mainly suffer from severe psychologic signs and symptoms. Additionally, pursuant to legal and ethical aspects of patient care, most patients have complex needs (Bee, Richards, Loftus, Baker, & Cox, 2006; Currid, 2009). Consequently, risks for suicide, self-harm, and violence (Rooney, 2009) create a potentially challenging care environment for psychiatric nurses (Howard & Holmshaw, 2010; Humble & Cross, 2010). CONTACT Malek Fereidooni-Moghadam © Taylor & Francis Group, LLC Fereidooni_moghadam@yahoo.com, Hughes and Umeh (2005) declared that caring for and managing patients, psychiatric nurses had conflicting roles causing stress. Accordingly, some issues that result in numerous problems for nurses working in psychiatric wards and even involve professionals’ own mental health have been reported in many studies (Chambers et al., 2015; McTiernan & McDonald, 2015; Pazargadi, Fereidooni Moghadam, Fallahi Khoshknab, Alijani Renani, & Molazem, 2015; Robinson, Clements, & Land, 2003) as follows: r having compassionate involvement with patients’ agonizing experiences, r encountering the same patients rotating in and out of services, r enjoying less palpability of interventions and outcomes compared with other nursing disciplines, r providing full-time care to patients with a variety of psychiatric disorders, and r working in a provocative environment beset with high levels of stress and distress. It is worth mentioning that in the psychiatric nurses’ environment, stress is highly prevailing, so it influences the provided care and staff health (Currid, 2009). The Royal College of Nursing (2005) reported that 40% of nurses in acute mental health care had signs of mental ill health and 14% of them were categorized as in distress. In Chambers et al.’s study (2015), psychiatric nurses experienced various psychological challenges and problems. To put in a nutshell, there is dearth of study on stress and challenges encountered by nurses in acute psychiatric settings Isfahan University of Medical Sciences, Isfahan, Iran. 2 K. ZAREA ET AL. and their threatening effects on the nurses’ health and profession (Abdalrahim, 2013); so it is important to address the issue at hand, especially from the perspective of the nurses themselves. Downloaded by [University of Florida] at 03:39 25 October 2017 Background in Iran In Iran, there are approximately 8600 psychiatric beds and over 123 psychiatric care centres offering specialized care to chronically and mentally ill patients (MoHME, 2011). Psychiatric nurses, assistant nurses, and service providers work in such centres. Nurses often have a bachelor’s degree or higher in nursing as the requirement for practice. Assistant nurses often have passed a 1-year education period in the field of nursing and perform routine patient care under the supervision of nurses. Service providers have attended a 6-month education period in psychiatric wards and are responsible for performing basic patient care activities such as activities of daily living (Zarea, Nikbakht-Nasrabadi, Abbaszadeh, & Mohammadpour, 2013). Psychiatric nursing education in the bachelor’s degree is composed of theoretical and clinical courses. Theoretical education includes basic and specialized education in relation to different aspects of psychiatric nursing. After the completion of theoretical courses, students participate in the clinical placement of practical courses in clinical psychiatric settings. Being performed in psychiatric wards, clinical placement usually is consisted of two 10-day education periods with the supervision of nurse instructors. Many nursing students after graduation are able to provide competent care for psychiatric patients (Pazargadi et al., 2015). After the completion of general and specialized courses during the 4 years of nursing education in Iran, nurses are certified to work in healthcare centres and are authorized to practise in different areas according to their interests and/or healthcare centres’ needs (Pazargadi et al., 2015). It should be noted that no specific entrance exam is available to select nurses for working in psychiatric wards (INO, 2011). Therefore, psychiatric nurses may not have sufficient knowledge and skills for working with mentally ill patients. According to the INO’s (Iranian Nursing Organization) report, psychiatric nurses are not appropriately selected for this job. Also, they often have been transferred to psychiatric wards due to poor performances in other nursing wards (INO, 2011; Zarea et al., 2013). There are a few qualitative studies on the experiences of nurses working in psychiatric wards in Iran. Zarea et al. (2013) reported that psychiatric nurses faced several socio-cultural and organizational challenges. Also, Soleimani, Sharifi, and Tehranidoost (2005) discovered that more than 55% of psychiatric nurses had the intense feelings of personal inadequacy. Also, they experienced fatigue, emotional exhaustion, and selfefficiency (Solimani et al., 2005). Therefore, the aim of this study was to explore challenges nurses face while working in acute psychiatric wards. Certainly, qualitative studies are important for the exploration of the experiences of nurses involved in the provision of care to patients with psychiatric disorders. Methods Design The qualitative study was carried out from 2014 to 2015. Participants were 15 nurses including 8 males and 7 females working in the psychiatric wards of four teaching hospitals affiliated to a university in the south of Iran. They were selected by using the purposive sampling method. Data was collected based on the nurses’ experiences of working in acute psychiatric wards. The inclusion criteria were as follows: having a bachelor’s degree or higher in nursing, at least 1-year work experience in psychiatric wards, and willingness to participate in this study. Data collection Semi-structured, face-to-face, and individual interviews were held with the nurses. The main questions asked in this study were: “Please tell me about your experiences of working in this ward?” and “What challenges do you face during working in this ward?”. To follow the participants’ thoughts and improve the depth of interviews, branching questions were asked. All interviews were tape-recorded and transcribed verbatim after each interview. The interviews were performed by the second author, who participated in the study as an observer, and lasted between 30 and 90 minutes. Data analysis was conducted consequently. According to the available guideline and studies (Elo & Kyngas, 2008; Zarea, Fereidooni-Moghadam, & Hakim, 2016), the data collection and analysis were continued until themes were developed and data saturation was reached. Data analysis For data analysis, an inductive content analysis was performed. Sentences were abridged into phrases and words to achieve patterns in data (Elo & Kyngas, 2008). To this end, the interviews were transcribed verbatim and considered as the unit analysis. The transcriptions were read several times to understand the general meaning behind the data. Meaningful units were identified as sentences or entire paragraphs. Primary codes were developed from the meaningful units, which were further categorized into more definite categories or sub-categories based on their similarities and differences. Finally, themes with regard to the underlying meanings in the interviews were extracted (Elo & Kyngas, 2008). Rigor Long-term engagement with the participants, reading the transcription several times to obtain the sense of whole, and peer checking helped with the credibility of the data. Also, the coded interviews were returned to some of the participants to ensure that the data collection and analysis were in line with the participants’ perspectives and thoughts (Holloway & Wheeler, 2010). ISSUES IN MENTAL HEALTH NURSING 3 Table . -A Summary of the Findings. Theme Experiencing psycho-social challenges Experiencing psychological challenges Encountering catalysts causing challenges Employing various strategies for coping with challenges Category Aﬀected quality of life, Perspective of the society, Losing professional identity, Work dissatisfaction Permanent stress and anxiety, Irritability, Eroding the sense of well-being, Sense of exhaustion, Continuous concerns about patients The patient health condition, A lack of requirements for ensuring professional competence, Limited role, The long-term presence of nurses in the psychiatric ward Active approaches Downloaded by [University of Florida] at 03:39 25 October 2017 Passive approaches Ethical considerations The Ethics Committee affiliated to Ahvaz Jundishapur University of Medical Sciences, Iran approved this study’s research proposal. The purpose and method of this study were described to the participants. They were ensured that their identity would not be revealed throughout the study process. The written informed consent form was signed by those participants who willingly agreed to take part in this study. Results In this study, 15 nurses held a bachelor’s or master’s degree in nursing. The range of the participants’ age was 25–53 years. They had 28 years of work experience in psychiatric wards. Four themes were developed from the data analysis: “experiencing psycho-social challenges,” “experiencing psychological challenges,” “encountering catalysts causing challenges,” and “employing various strategies for coping with challenges” (Table 1). Experiencing psycho-social challenges Several psycho-social challenges were notified by the nurses in the study. The nurses stated that their quality of work life and personal life were affected by encountering different challenges, as one of them declared that: “After work, I went home and realized that my mood was affected. I realized that I experienced discomfort in my work shift, because two patients had conflicts together, and I had to restrain them. Now, I am feeling unhappy, because it certainly involved my personal life.” (Participant No. 11). Another nurse asserted that: “ … I often become irritable; I cannot tolerate it anymore. It can be said I’ve become depressed or the quality of my life has been affected.” (Participant No. 5). Another challenge which was experienced by the psychiatric nurses was the social perspectives towards nurses who provided care to mentally ill patients and were labelled with negative terms: Sub-Category Transfer requests, Interactions with colleagues Avoiding the patient, Avoiding the patient-related activities, Inevitable adaptation strategies “Many people have a different perspective towards nurses working in the psychiatric ward. For example, you see that we have financial problems or a problem with our working hours. I may speak with administrative staff and raise my voice a little bit. He/she then may say: ‘Oh, this nurse has been affected because of caring for mentally ill patients”’ (Participant No. 8). Another nurse expressed how the society negatively considered nurses and labelled them unprofessional as follows: “The society and even healthcare officials do not have an appropriate perspective toward the psychiatric ward. Surprisingly, our family members also label us negatively. If I become angry, well, I may really become angry, whatever I do, they say: ‘Since he/she works in a psychiatric ward, he/she may have a problem himself/herself [psychological problem]’.” (Participant No. 6). Losing professional identity and work dissatisfaction were also mentioned as some psychosocial consequences of working in a psychiatric ward. One nurse expressed her job dissatisfaction as follows: “I have no job satisfaction, or in other words, I do not feel that the work that I do here is specialized. Perhaps my physical workload here is less than other wards, but I have no job satisfaction. I do not know what on earth I am doing here.” (Participant No. 5). Experiencing psychological challenges Another main theme was the psychological challenges of working in the psychiatric ward. Nurses in this study reported a range of psychological effects from working in this environment: “Working with a mentally ill patient is really a very difficult task. There is always the possibility of conflict with the patients, because in the long term, they can affect the nurse’s mental well-being. Most nurses working in the psychiatric ward begin to experience unpleasant conditions or even show some psychiatric symptoms.” (Participant No. 8). Several nurses shared their experiences of stress and anxiety as follows: “Well, you know, I am constantly worried and stressed out all times. Beyond that I’ll be hurt by the patient, I am afraid that the patient may harm himself/herself.” (Participant No. 2). “I have always said to myself: ‘Oh, when I enter the ward, I do not know what will happen, how many patients should be controlled 4 K. ZAREA ET AL. for their dangerous behaviours, how many patients may become aggressive toward me or throw objects at me, and most importantly, how many patients may try to escape from the ward! These are the sources of stress that always I face in the ward.” (Participant No. 6). Irritability was felt as one of the negative consequences of working in the psychiatric ward: “ … I become irritable easily; I don’t have any tolerance and often lose my temper.” (Participant No. 5). Other psychological consequences expressed by the nurses were the eroding sense of well-being and sense of exhaustion: “ … This concern [concern about the patient] always makes my mind busy, and I feel that I am being gradually worn down.” (Participant No. 2). Downloaded by [University of Florida] at 03:39 25 October 2017 “ … I am feeling really worn down, I think I cannot go on here … I am really exhausted.” (Participant No. 5). Lastly, a continuous concern about patients was another psychological challenge of working in the psychiatric ward: “Working with psychiatric patients may not be easily accepted by others. For instance, when going home from the workplace, the nurse, who is physically tired, is always worrying about a patient who has suicidal thoughts. As a nurse, I worry that something bad might happen to she/he with such suicidal thoughts. Though informing other clinicians of such a thing by writing the patient’s status in the medical records and asking them to carefully observe or control for his/her potentially dangerous behaviours, but the nurse still remain worried. The nurse always is ready to hear bad news about the patient.” (Participant No. 6). Another nurse described her/his concerns as follows: “ … My mind is involved in the patient’s care. The patient may have a range of symptoms, taking some drugs. When the patient is discharged from the hospital, his/her file is closed. However, some patients may leave, but their health files remain open in my mind or even my soul. This means that I think about whether or not those patients that have left the ward are doing well or their problems have been solved. Thus, in a part of my mind, my feelings towards the patient are involved.” (Participant No. 2). Encountering catalysts causing challenges This theme referred to reasons and factors that provoked or caused challenges for nurses while caring for psychiatric patients. Patients’ health conditions, their symptoms, and the nature of their disorders were some causes for concerns. “I am very emotional; sometimes the life of some of them [patients] is so painful that anyone would be affected. Of course, a nurse working in other wards may become involved in the familial and physical problems of them. He/she only resolves the physical problems of the patient. However, that is not the case at the psychiatric ward. Here, I have a kind of emotional involvement with the patient’s problems, because of the emotional nature of the problem. This inevitably has an impact on me as a nurse.” (Participant No. 17). “ … I cannot say that working here does not affect me. When I find the patient’s problems, they definitely affect me. For example, some patients come from prison and have criminal records, and I must take care of them. Of course, it has an impact on me.” (Participant No. 6). The lack of requirements for ensuring professional competence among psychiatric nurses was another factor resulting in negative effects on the nurses. This discontentment expressed by the nurses, in addition to other factors, may be due to both lack of job satisfaction and their limited role in providing care. One nurse expressed her unpleasant mental state as follows: “ … really they are not just nursing tasks, I feel like I can do much more than I did. Nurses might have many roles in the society and in the psychiatric ward. I feel that my work actually is a kind of repetitive chain of actions and I’m able to do more for the patient. Actually, I do not feel that I am doing my role properly. The control of events is my main task. When I arrive at home from work, I don’t feel good.” (Participant No. 11). The elongated presence that nurses must maintain in the psychiatric ward was mentioned as one of the most important effective factors: “ … Well, I might get tired after seven years of working in this ward. Work rotations should be implemented in healthcare staff. After working here for two years, I’ve lost my motivation. This is not good, it really affects me.” (Participant No. 2). Employing various strategies for coping with challenges The nurses noticed that they had used various strategies and actions for dealing with physical and psychological problems in the psychiatric ward. Some of these strategies were done actively and consciously by the nurses, but the other ones were passive in nature and actually the nurses were compelled to use them. These two major strategies were labelled as active and passive approaches. Passive approaches involved inevitable coping strategies that nurses attempted to eventually use in practice. One of these strategies was evading doing principled work; in other words, the nurses evade doing principled work to reduce the negative effects of working with mentally ill patients. “ … [There is] a large amount of work and the working environment is challenging. Since work is not standardized, a great amount of stress is imposed on nurses. If the nurse wants to work according to principles and standards, he/she definitely experiences problems. The nurse is unable to meet the patient and his/her family members’ needs as well.” (Participant No. 5). “I did not want to work in the psychiatric ward, but I had no choice. As a result, I always fulfil my work shifts just and then I leave.” (Participant No. 17). Other nurses expressed some inevitable adaptation strategies as follows: “I have to deal with anxiety. It would have worn me out, if I’d thought about it too much.” (Participant No. 3). “ … I’ve begun to adapt gradually. I’ve just adapted to this situation.” (Participant No. 2). Active approaches to manage the effects and consequences of working with psychiatric patients were also mentioned as another strategy applied by nurses working in the psychiatric wards. They highlighted a need for a change in the workplace in order to mitigate the negative consequences of patient care. For instance, some nurses suggested the need for personnel rotations: “ … Well, there should be rotation for nurses. Why should I stay in this ward for two years or more? I’ll lose my work motivation and only negative feelings will remain, if I stay in this ward.” (Participant No. 2). ISSUES IN MENTAL HEALTH NURSING “ … The workplace needs to be changed after a while. Monotony, not only in the psychological ward but also in other wards can reduce nurses’ work motivation and satisfaction. Surely, this is crucial for nurses who are working in the psychiatric ward to change their workplace ….” (Participant No. 5). Interacting with colleagues was also mentioned as a coping mechanism used by nurses to overcome the negative consequences of working in the psychiatric ward: “We sit together, sometimes we talk about our patients. We chat with one another, drink tea together, and alleviate our stress” (Participant No. 3). Another active approach for adaptation was mentioned as transfer requests: Downloaded by [University of Florida] at 03:39 25 October 2017 “ … Because of the constant stress, anxiety, and tension in this ward, I had to request for a transfer from here.” (Participant No. 2). “Why does nobody want to get stuck in this ward and after a while everyone wants to leave it? It is because of stress and anxiety. I have also requested for a transfer from this ward several times.” (Participant No. 6). Discussion Psychiatric nursing aims to provide high quality care to patients suffering from mental disorders. However, the provision of care to such patients is accompanied with some challenges. Since a few qualitative studies had been found on this phenomenon with a focus on nurses’ perspectives in Iran, this study was conducted to explore the perspectives of 15 nurses working in psychiatric wards of selected hospitals in an urban area in the south of Iran. The nurses in this study were involved in the psycho-social challenges such as the society’s perspective towards nursing practice, in which nurses working in psychiatric wards and with mentally ill patients was negatively labelled. Nurses expressed that such perspectives negatively affected their practice, quality of work life, and personal life. In addition, nurses expressed a loss of professional identity and job dissatisfaction as the psycho-social consequences of their practice in the psychiatric ward, which influenced their practice and interactions with patients. In the realm of psychiatric nursing, there is a certain stigma on mental illnesses and the treatment of mentally ill patients, which is derived from the history of psychiatric care in which mentally ill patients are labelled as insane. It is indirectly extended to nurses and those working with mentally ill patients. Such ideas have led to the feelings of frustration, shame, despair, and society’s confusion over the issue that mental illnesses influence psychiatric nurses (Happell, 2008; Humble & Cross, 2010). The results of the study by Li and Zhao (2004) showed that high levels of mental stress in Chinese psychiatric nurses were related to negative attitudes of the society towards them and their work with mentally ill patients. Also, they were not fully understood by patients and their family members. In Iran, studies generally indicated the poor perception of nurses’ roles in the Iranian society. Iranian ancient texts and poems depicted a poor cultural background on nursing care (Nikbakht-Nasrabadi, Emami, & Parsa-Yekta, 2003; Zarea et al., 2009). In the study by Zarea et al. (2013), the experiences of nurses working in psychiatric wards using a phenomenological 5 approach were explored. Cultural and social challenges that nurses faced were mostly due to negative attitudes of the society. Such a poor image stemmed from the fact that the behaviours of nurses interacting with patients with mental disorders surely will be affected. The perception of Iranian nurses was also negatively affected by the generally negative perception of the society towards nursing (Zarea et al., 2013). Experiencing psychological challenges by nurses was revealed as another theme in this study. Such challenges encompassed a wide range of psychological symptoms and mental disorders including stress and anxiety, irritability, and constant concern for patients. Various researchers declared that as a discipline, mental health nursing was highly associated with stress and exhaustion. It is believed that psychiatric nurses experience higher levels of emotional exhaustion and stress in comparison with other occupational groups (Abdalrahim, 2013; McTiernan & McDonald, 2015). A qualitative study conducted by Ward (2011) showed that the findings of their investigation unanimously supported current literature on the issue that mental health nursing was a stressful profession. The Royal College of Nursing discovered that 40% of nurses in England, Northern Ireland, Scotland, and Wales showed the symptoms of mental disorders and 14% of them were distressed out (Royal College of Nursing, 2005). In addition, Chambers et al. (2015) found that nurses experienced psychological challenges and problems including cognitive dissonance, conflicts between benevolence and malevolence, and feelings of fear, anxiety, and vulnerability. Also, the study carried out by Kindy, Petersen, and Parkhurst (2005) reported that nurses’ personal life was negatively affected even when they were outside of the workplace. It is worth mentioning that one of the themes extracted in the study by Currid (2009) was the inability of nurses to separate from work. They were unable to stop thinking about their work after arriving at their own homes. In the current study, encountering catalysts causing challenges was found as another theme. In particular, the severity of patients’ conditions and the nature of the patients’ disorder and symptoms, especially their aggressive behaviours were mentioned as significant factors underlying the negative consequences of working in the psychiatric ward. According to some researchers, the high levels of stress among nurses were associated with ongoing conflicts and the interactions of psychiatric nurses with patients suffering from severe mental disorders (Taylor & Barling, 2004). Working in sealed units and providing care for patients being in dire need of nonstop observation and intricate treatment programs, psychiatric nurses are put in jeopardy of various tough work-related stressors (White, 2006). In addition, psychiatric nurses have closer communications and relationships with their patients and are involved in the prevention of self-harming behaviours. Therefore, they often encounter a greater number of challenging patients in their workplace (Currid, 2009). Moreover, violent attacks and threats from patients and their relatives have become growing concerns in psychiatric wards and are some of the most significant factors associated with staff stress and anxiety (Currid, 2009). The lack of requirements for ensuring professional competence among psychiatric nurses and the limited role of nursing Downloaded by [University of Florida] at 03:39 25 October 2017 6 K. ZAREA ET AL. activities were also expressed as factors that negatively affected psychiatric nurses. Many nurses stated that caring tasks in the psychiatric ward did not correspond to their subjective ideals and mainly included routine and repetitive tasks such as medication administration or patients’ control. Therefore, these activities did not provide opportunities for nurses to improve their competencies. Cleary, Walter, and Hunt (2005) reported that 35% of psychiatric nurses believed that the reality of mental health care was different from their initial expectations. Therefore, there are fundamental differences between ideals in mental health care and the reality of clinical practice in psychiatric wards (Cleary et al., 2005). The long-term presence of nurses in the psychiatric ward was another factor mentioned by the nurses. Nurses considered their long presence in the ward mandatory and often due to the high demand for mental health care by nursing professionals. Therefore, they experienced dissatisfaction and physical or mental problems. Ward and Cowman (2007) showed that psychiatric nurses who had a right to choose their workplace enjoyed greater satisfaction with their profession. “Employing various strategies for coping with challenges” was the fourth extracted theme in the study. In other words, nurses exhibited some coping strategies in order to reduce or eliminate the impact of the negative aspects of their work. The strategies included both passive and active approaches. Passive approaches involved avoiding from the patient and their related-activities. Necessary adaptation was also expressed as another passive approach among nurses for coping with the consequences of working in the psychiatric ward. Nurses’ withdrawal from having interactions with patients was previously suggested by another study (Fourie, McDonald, Connor, & Bartlett, 2005). This may be the result of working in acute hospital settings and an attempt by nurses to protect themselves from burnout (Mullen, 2009). Psychiatric nurses work in an environment with high emotional engagement and demanding patients. In such situations, psychiatric nurses used coping strategies to escape from patients and their ever-increasing demands (Fisher, 2011). Also, nurses’ work environment has a significant impact on nursing practice and outcomes of psychiatric care. Therefore, the importance of nurses’ engagement in psychiatric care have been emphasized (Gabrielsson, Sävenstedt, & Olsson, 2016; Polacek et al., 2015). Psychiatric nurses also used active approaches to mitigate the effects and consequences of working with psychiatric patients. Such methods were used consciously and purposefully by the nurses. Nurses mentioned they needed to change their environment and also requested to be transferred from the psychiatric ward to other wards. Another active adaptation approach was the interaction with other colleagues for reducing stress and finding solutions for their concerns regarding patient care. Other studies showed that nurses applied different coping strategies to deal with stress. For example, nurses impatiently waited for the end of their shift to go home and to talk to friends and colleagues with whom they had a close relationship (Cai, Li, & Zhang, 2008). Positive coping strategies were also described in the study of Cai et al. (2008). They stated that psychiatric nurses attempted to recognize the positive aspects of their situation, entertain themselves, participate in nursing activities, talk to others regarding their problems, and remember their important life values (Cai et al., 2008). On the other hand, because of work-related stress in psychiatric wards, some nurses preferred to change their work environment; hence, such views have led to nurse shortages and losing staff in the field of psychiatric nursing. In other studies, this was one of the barriers to the provision of high quality care (Zarea et al., 2013). In Iran, working as a nurse in the mental health setting is represented as the last resort for nurses (Zarea et al., 2013). Conclusion The results of this study showed that the provision of care to patients with severe mental disorders in the psychiatric ward led to several physical, psychological, and social consequences for nurses. Given the importance of the physical and mental well-being of nurses and the moral and professional responsibility of organization to protect staff health, it’s significant to examine the inpatient psychiatric nurses’ experiences to better understand their experience and hopefully use that knowledge to enhance their work life. Few nurses are interested in the specialty, especially working in inpatient areas. We have got to know more about their work-life experience so that improvements can be made and the retention of nurses can be improved. Then, more research, especially qualitative studies in this area is recommended. Acknowledgments The researcher gratefully thanks the Deputy of Research and Technology, Ahvaz Jundishapur University of Medical Sciences for their financial and spiritual support. The researcher also acknowledges with gratitude the cooperation of the nurses who participated to this study. Conflict of interest The authors declare that there is no conflict of interest. References Abdalrahim, A. (2013). Stress and coping among psychiatric nurses. Middle East Journal of Nursing & Health Sciences, 7, 20–37. Barker, P. (2009). An overview of the assessment process: Bringing life into the light, Assessment in psychiatric and mental health nursing in search of the whole person. Cheltenham: Stanley Thornes Ltd. Bee, P. E., Richards, D. A., Loftus, S. K. L., Baker, J. A., & Cox, D. (2006). Mapping nursing activity in acute inpatient mental healthcare settings. Journal of Mental Health, 15(2), 217–226. Cai, Z.-X., Li, K., & Zhang, X.-C. (2008). Workplace stressors and coping strategies among chinese psychiatric nurses. Perspectives in Psychiatric Care, 44(4), 223–231. Carson, J., Leary, J., de Villiers, N., Fagin, L., & Radmall, J. (1995). Stress in mental health nurses: Comparison of ward and community staff. British Journal of Nursing, 4(10), 579–582. https://doi.org/10.12968/bjon.1918.104.22.1689 Chambers, M., Kantaris, X., Guise, V., & Valimaki, M. (2015). Managing and caring for distressed and disturbed service users: the thoughts and feelings experienced by a sample of English mental health nurses. Journal of Psychiatric and Mental Health Nursing, 22(5), 289–297. https://doi.org/10.1111/jpm.12199 Cleary, M., Walter, G., & Hunt, G. (2005). The experience and views of mental health nurses regarding nursing care delivery in an integrated, inpatient setting. International Journal of Mental Health Nursing, 14, 72–77. Currid, T. (2009). Experiences of stress among nurses in acute mental health settings. Nursing Standard, 23(44), 40–46. Downloaded by [University of Florida] at 03:39 25 October 2017 ISSUES IN MENTAL HEALTH NURSING Dallender, J., Nolan, P., Soares, J., Thomsen, S., & Arnetz, B. (1999). A comparative study of the perceptions of British mental health nurses and psychiatrists of their work environment. Journal of Advanced Nursing, 29(1), 36–43. Elo, S. & Kyngas, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. Fisher, J. (2011). The therapeutic role of the mental health nurse: Implications for the practice of psychological therapies [dissertation]. Southern Cross University, Lismore, NSW. Fourie, W. J., McDonald, S., Connor, J., & Bartlett, S. (2005). The role of the registered nurse in an acute mental health inpatient setting in New Zealand: Perceptions versus reality. International Journal of Mental Health Nursing, 14(2), 134–141. Gabrielsson, S., Sävenstedt, S., & Olsson, M. (2016). Taking personal responsibility: Nurses’ and assistant nurses’ experiences of good nursing practice in psychiatric inpatient care. International Journal of Mental Health Nursing, 25(5), 434–443. https://doi.org/10.1111/inm.12230 Happell, B. (2008). Clinical experience in mental health nursing: Determining satisfaction and the influential factors. Nurse Education Today, 28(7), 849–855. Holloway, I. & Wheeler, S. (2013). Qualitative research in nursing and healthcare (3rd ed.). Oxford: Wiley-Blackwell. Howard, V. & Holmshaw, J. (2010). Inpatient staff perceptions in providing care to individuals with co-occurring mental health problems and illicit substance use. Journal of Psychiatric and Mental Health Nursing, 17, 862–872. Hughes, H. & Umeh, K. (2005). Work stress differentials between psychiatric and general nurses. British Journal of Nursing, 14(15), 802–808. https://doi.org/10.12968/bjon.2005.14.15.18597 Humble, F. & Cross, W. (2010). Being different: A phenomenological exploration of a group of veteran psychiatric nurses. International Journal of Mental Health Nursing, 19, 128–136. https://doi.org/10.1111/j.14470349.2009.00651.x INO. (2011). Annual Report. Tehran: Iranian Nursing Organization. [In Persian]. Jenkins, R. & Elliott, P. (2004). Stressors, burnout and social support: nurses in acute mental health settings. Journal of Advanced Nursing, 48(6), 622–631. https://doi.org/10.1111/j.1365-2648.2004.03240.x Kindy, D., Petersen, S., & Parkhurst, D. (2005). Perilous work: Nurses’ experiences in psychiatric units with high risks of assault. Archives of Psychiatric Nursing, 19(4), 169–175. Li, H. & Zhao, Y. (2004). Investigation and analysis on psychiatric nurses’ stressors. Clinical Nursing, 3(2), 5–7. McGrath, A., Reid, N., & Boore, J. (2003). Occupational stress in nursing. International Journal of Nursing Studies, 40, 555–565. McTiernan, K., & McDonald, N. (2015). Occupational stressors, burnout and coping strategies between hospital and community psychiatric nurses in a Dublin region. Journal of Psychiatric and Mental Health Nursing, 22(3), 208–218. https://doi.org/10.1111/jpm.12170 Moghadam, M. F., Pazargadi, M., & Khoshknab, M. F. (2013). Iranian nurses’ experiences of aggression in psychiatric wards: A qualitative study. Issues in Mental Health Nursing, 34(10), 765–771. https://doi.org/10.3109/01612840.2012.737893 7 MoHME. (2011). Annual Report. Tehran: MoHME, Ministry of Health and Medical Education. [in Persian]. Mullen, A. (2009). Mental health nurses establishing psychosocial interventions within acute inpatient settings. International Journal of Mental Health Nursing, 18, 83–90. Nikbakht-Nasrabadi, A., Emami, A., & Parsa-Yekta, Z. (2003). Nursing experience in Iran. International Journal of Nursing Practice, 9, 78–85. Pazargadi, M., Fereidooni Moghadam, M., Fallahi Khoshknab, M., Alijani Renani, H., & Molazem, Z. (2015). The therapeutic relationship in the shadow: Nurses’ experiences of barriers to the nurse-patient relationship in the psychiatric ward. Issues in Mental Health Nursing, 36(7), 551–557. https://doi.org/10.3109/01612840.2015.1014585 Polacek, M. J., Allen, D. E., Damin-Moss, R. S., Schwartz, A. J., Sharp, D., Shattell, M., … Delaney, K. R. (2015). Engagement as an element of safe inpatient psychiatric environments. Journal of the American Psychiatric Nurses Association, 21(3), 181–190. https://doi.org/10.1177/1078390315593107 Robinson, J., Clements, K., & Land, C. (2003). Workplace stress among psychiatric nurses. Prevalence, distribution, correlates, & predictors. Journal of Psychosocial Nursing Mental Health Services, 41(4), 32–41. Rooney, C. (2009). The meaning of mental health nurses experience of providing one-toone observations: a phenomenological study. Journal of Psychiatric and Mental Health Nursing, 16, 76–86. Royal College of Nursing. (2005). At breaking point? A survey of the wellbeing and working lives of nurses in 2005. Retrieved from http://www.rcn.org.uk/__data/assets/pdf_file/0003/78690/003021.pdf Solimani, K., Sharifi, V., & Tehranidoost, M. (2005). Burnout in the Roozbeh’ clinical staff. [Tazehaye Olome Shenakhti] in Persian, 7, 36–42. Taylor, B., & Barling, J. (2004). Identifying sources and effects of carer fatigue and burnout for mental health nurses: A qualitative approach. International Journal of Mental Health Nursing, 13, 117–125. Ward, L. (2011). Mental health nursing and stress: Maintaining balance. International Journal of Mental Health Nursing, 20(2), 77–85. https://doi.org/10.1111/j.1447-0349.2010.00715.x Ward, M. & Cowman, S. (2007). Job satisfaction in psychiatric nursing. Journal of Psychiatric and Mental Health Nursing, 14, 454–461. White, R. A. (2006). Perceived stressors, coping strategies, and burnout pertaining to psychiatric nurses working on locked psychiatric units, Master theses and doctoral dissertation, Eastern Michigan University, USA. Zarea, K., Fereidooni-Moghadam, M., & Hakim, A. (2016). Adherence to medication regimen in patients with severe and chronic psychiatric disorders: A qualitative study. Issues in Mental Health Nursing, 37(11), 868–874. https://doi.org/10.1080/01612840.2016.1239147 Zarea, K., Negarandeh, R., Dehghan-Nayeri, N., Rezaei-Adaryani M. (2009). Nursing staff shortages and job satisfaction in Iran: Issues and challenges. Nursing & Health Sciences, 11, 326–331. Zarea, K., Nikbakht-Nasrabadi, A., Abbaszadeh, A., & Mohammadpour, A. (2013). Psychiatric nursing as ‘different’ care: experience of Iranian mental health nurses in inpatient psychiatric wards. Journal of Psychiatric and Mental Health Nursing, 20, 124–133.