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Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/ M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved from: https://ujdigispace.uj.ac.za (Accessed: Date).
LIVED EXPERIENCES OF STUDENT NURSES CARING FOR
INTELLECTUALLY DISABLED PEOPLE IN A PUBLIC PSYCHIATRIC
INSTITUTION
By
GANYANI LIZZIE SIMELANE
A dissertation submitted as a partial fulfilment for the
MAGISTER CURATIONIS
In
PSYCHIATRIC NURSING
in the
FACULTY OF HEALTH SCIENCES
At the
UNIVERSITY OF JOHANNESBURG
SUPERVISOR: DR. A. TEMANE
CO-SUPERVISORS: PROF. M. POGGENPOEL
PROF. C.P.H. MYBURGH
i
DEDICATION
I dedicate this Minor-dissertation to my family, friends and colleagues.
Thank you for your support and encouragement throughout my studies. Your
love, patience and belief in me helped me to persevere and stay positive and complete
my studies.
ii
ACKNOWLEDGEMENTS
To God, for giving me the opportunity to do my minor-dissertation and for giving me the
strength and ability to finish my studies.
To Dr. Annie Temane, Prof. Marie Poggenpoel and Prof. Chris Myburgh for their
mentoring, support and encouragement.
To Mrs. Leatitia Romero for the language and technical editing.
To the participants of the study, student nurses, who shared their experiences.
To my family and friends for their support and patience during the study.
iii
ABSTRACT
Caring for intellectually disabled people can be demanding for student nurses who are
still novices in the profession. To ensure optimal nursing care is received, student
nurses must have both an understanding of and a positive attitude towards intellectually
disabled people. Nursing intellectually disabled people is a challenge that can have an
impact on a person‟s body, mind and spirit therefore, student nurses need to have the
ability to deal with stressful situations and environments.
Student nurses need to be prepared to care for patients with long-term challenges, such
as intellectual disabilities. These patients require a caring relationship that facilitates an
enhanced awareness of life and health experiences. The caring relationship also
facilitates health and healing processes as it involves the authentic and genuine needs
of patients.
This research aimed to explore and describe lived experiences of student nurses caring
for intellectually disabled people in a public psychiatric institution, and to formulate
guidelines for the facilitation of mental health of these student nurses.
A qualitative, exploratory, descriptive and contextual design was used. Data were
collected through individual in-depth interviews, focusing on the question “How was it for
you to be working at this institution?” Thematic analysis was used to analyse the
collected data and a consensus discussion was held with the independent coder. Ten
participants were interviewed and five, who were not comfortable with interviews, wrote
naïve sketches. Trustworthiness was assured by adhering to Lincoln and Guba‟s
principles, that is, credibility, transferability, dependability, and confirmability. Four
ethical principles were demonstrated throughout the research namely, principles of
respect for autonomy, non-maleficence, beneficence, and justice.
Three themes emerged from the data. Firstly, student nurses experience a profound
unsettling impact on their wholistic being when caring for intellectually disabled people.
iv
Secondly, they develop a sense of compassion and a new way of looking at life, and
lastly they require certain educational, emotional and spiritual needs to be met.
Guidelines were formulated to facilitate the mental health of student nurses caring for
intellectually disabled people in a public psychiatric institution.
v
OPSOMMING
Die versorging van verstandelikgestremde mense kan veeleisend wees vir
studentverpleegsters wat nog onervare in die professie is. Om te verseker dat optimale
verplegingsorg ontvang word, moet studentverpleegsters beide ʼn begrip van en ʼn
positiewe gesindheid teenoor verstandelikgestremde mense hê. Die verpleging van
mense met verstandelikgestremdhede is ‟n uitdaging wat ʼn impak kan hê op ʼn persoon
se liggaam, verstand en gees, desnieteenstaande moet studentverpleegsters die
vermoë hê om stresvolle situasies en omstandighede te hanteer.
Studentverpleegsters moet voorbereid wees om pasiënte met langtermyn uitdagings,
soos verstandelikgestremdheid, te versorg. Hierdie pasiënte benodig ʼn versorgende
verhouding wat ʼn verhoogde bewustheid van die lewe en gesondheidservarings
fasiliteer. Die versorgende verhouding fasiliteer ook gesondheids- en
genesingsprosesse aangesien dit die opregte en ware behoeftes van die pasiënte
betrek.
Die navorsing het gepoog om die ervarings van studenteverpleegsters wat
verstandelikgestremde mense in ʼn publieke psigiatriese instansie versorg te eksploreer
en te beskryf, en om riglyne vir die fasilitering van die geestesgesondheid van hierdie
verpleegstudente te formuleer.
ʼn Kwalitatiewe, verkennende, beskrywende en kontekstuele ontwerp was gebruik. Data
was ingesamel deur individuele indiepte onderhoude wat op die vraag, “Hoe was dit vir
jou om by hierdie instansie te werk?” gefokus het. Tematiese analisie was gebruik om
die ingesamelde data te analiseer en ʼn konsensus gesprek was met die onafhanklike
kodeerder gehou. Daar was onderhoude gevoer met tien deelnemers, en vyf wat nie
gemaklik met die onderhoude was nie, het naïve sketse geskryf. Vertrouenswaardigheid
was verseker deur Lincoln en Guba se beginsels te volg, naamlik geloofwaardigheid,
oordraagbaarheid, afhanklikheid en bevestiging. Vier beginsels, naamlik die beginsels
vi
van respek vir outonomie, nie-kwaadwilligheid, goedwilligheid en geregtigheid, was
deurlopend deur die studie gedemonstreer.
Drie temas het uit die data te voorskyn gekom. Eerstens, studentverpleegsters ervaar ʼn
diepliggande uitdagings wanneer hulle verstandelikgestremde mense versorg.
Tweedens ontwikkel hulle deernis en ʼn nuwe uitkyk op die lewe, en laastens benodig
hulle dat sekere opvoedkundige, emosionele en spirituele behoeftes nagekom word.
Riglyne was geformuleer om die geestesgesondheid van studentverpleegsters wat
verstandelikgestremde mense in ʼn publieke psigiatriese instansie versorg, te fasiliteer.
vii
TABLE OF CONTENT
DEDICATION i
ACKNOWLEDGEMENTS ii
ABSTRACT iii
OPSOMMING v
CHAPTER 1
INTRODUCTION, RATIONALE AND OVERVIEW
1.1 INTRODUCTION 1
1.2 BACKGROUND AND RATIONALE 2
1.3 PROBLEM STATEMENT 5
1.4 RESEARCH PURPOSE 6
1.5 RESEARCH OBJECTIVES 6
1.6 PARADIGMATIC PERSPECTIVE 6
1.6.1 Meta-theoretical assumptions 7
1.6.1.1 Person 7
1.6.1.2 Mental health 7
1.6.1.3 Environment 7
1.6.1.4 Psychiatric nursing 8
1.6.2 Theoretical assumption 8
1.6.2.1 Definition of central concepts 8
1.6.3 Methodological assumptions 9
1.7 RESEARCH DESIGN AND METHOD 10
1.7.1 Research design 10
1.7.2 Research method 10
1.7.2.1 Phase 1: Exploration and description of student nurses‟ lived experiences
caring for intellectually disabled people in a public psychiatric institution 10
a) Population and sample 10
viii
b) Data collection 11
c) Data analysis 11
d) Literature control 12
1.7.2.2 Phase 2: Description of guidelines to facilitate mental health of student
nurses caring for intellectually disabled people in a public psychiatric
institution 12
1.8 MEASURES TO ENSURE TRUSTWORTHINESS 12
1.8.1 Credibility 12
1.8.2 Transferability 13
1.8.3 Dependability 13
1.8.4 Confirmability 13
1.9 ETHICAL CONSIDERATIONS 14
1.10 CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS 15
1.11 DIVISION OF CHAPTERS 15
1.12 SUMMARY 16
CHAPTER 2
RESEARCH DESIGN AND METHOD
2.1 INTRODUCTION 17
2.2 RESEARCH DESIGN 17
2.2.1 Qualitative research 17
2.2.2 Exploratory research 18
2.2.3 Descriptive research 19
2.2.4 Contextual research 19
2.3 RESEARCH METHOD 20
2.3.1 Phase 1: Exploring and describing lived experiences of student nurses
caring for the intellectually disabled people in a public psychiatric
institution 20
2.3.1.1 Population and sampling 21
ix
2.3.1.2 Data collection 22
a) In-depth interviews 22
b) Pilot study 24
c) Field notes 25
c.i) Theoretical notes 25
c.ii) Methodological notes 26
c.iii) Observational notes 26
c.iv) Personal notes 26
d) Role of the researcher 26
2.3.1.3 Data analysis 27
2.3.2 Phase 2: Guidelines for the facilitation of mental health of student
nurses caring for intellectually disabled people in a public psychiatric
institution 28
2.3.3 Measures to ensure trustworthiness 28
2.3.3.1 Credibility 28
a) Prolonged engagement 30
b) Triangulation 31
c) Reflexivity 31
d) Member checking 31
e) Peer examination 32
f) Authority of the researcher 32
g) Structural coherence 32
2.3.3.2 Transferability 32
2.3.3.3 Dependability 33
2.3.3.4 Confirmability 33
2.4 ETHICAL CONSIDERATIONS 34
2.5 SUMMARY 34
x
CHAPTER 3
RESULTS AND DISCUSSION OF RESULTS -LIVED EXPERIENCES OF STUDENT
NURSES CARING FOR INTELLECTUALLY DISABLED IN A PUBLIC PSYCHIATRIC
INSTITUTION
3.1 INTRODUCTION 35
3.2 DESCRIPTION OF THE DEMOGRAPHIC PROFILE OF THE
TARGET POPULATION AND SAMPLE 35
3.3 DISCUSSION OF RESULTS AND LITERATURE CONTROL 36
3.3.1 THEME 1: STUDENT NURSES EXPERIENCE A PROFOUNDLY
UNSETTLING IMPACT ON THEIR WHOLISTIC BEING WHEN
CARING FOR INTELLECTUALLY DISABLED PEOPLE 37
3.3.1.1 Body 38
a) Experience strange noises made by intellectually disabled people 38
b) Experience unhygienic smells in the wards 39
c) Experience seeing all the deformed bodies as well as the way food
was served 41
d) Experience discomfort and uncertainty with regard to physical
handling of the intellectually disabled people 44
e) Experience lack of appetite 45
3.3.1.2 Mind of student nurses 46
a) Affecting their own view on parenthood 46
b) Realised the needs of the intellectually disabled people 47
3.3.1.3 Spirit of student nurses 48
a) Experience ethical issues when caring for intellectually disabled
people 48
b) Experience inner conflict when caring for intellectually disabled
people 49
c) Experience that they are struggling to see the purpose of intellectually
disabled people‟s lives 50
xi
3.3.2 THEME 2: STUDENT NURSES EXPERIENCE A SENSE OF COMPASSION
AND A NEW WAY OF LOOKING AT LIFE 51
3.3.2.1 Experience a deep level of empathy towards intellectually disabled
people and nursing personnel of the public psychiatric institution 52
3.3.2.2 Experience an awareness of injustices 54
3.3.2.3 Experience an awareness of responsibility of families and
communities 55
3.3.2.4 Experience an awareness of personal abilities 56
3.3.2.5 Experience a sense of gratitude 57
3.3.2.6 Experience gratitude when caring for intellectually disabled people 57
3.3.2.7 Experience awareness of their own opportunities in life 58
3.3.3 THEME 3: STUDENT NURSES EXPERIENCE A NEED TO COPE WHILE
CARING FOR INTELLECTUALLY 59
3.3.3.1 Experience educational needs 59
a) Experience a need for frequent visits of tutors to the ward 60
b) Experience need of practical guidance during training sessions of
how to physically handle the intellectually disabled people 61
c) Experience a need for guidance, support and effective role modelling
of the public psychiatric institution‟s personnel 62
3.3.3.2 Experience emotional needs 63
a) Experience a need for preparation before working in the institution like
what to expect when caring for intellectually disabled people 63
b) Experience a need for group discussions while working in the
institution to ventilate 64
c) Experience a need for reflective group discussion after working in the
Institution 65
3.3.3.3 Experience spiritual needs 66
a) Experience need for a guidance by a spiritual director on different
topics 67
3.4 FIELD NOTES 68
3.5 SUMMARY 68
xii
CHAPTER 4
GUIDELINES FOR THE FACILITATION OF MENTAL HEALTH OF STUDENT
NURSES CARING FOR INTELLECTUALLY DISABLED PEOPLE IN A PUBLIC
PSYCHIATRIC INSTITUTION, LIMITATIONS, RECOMMENDATIONS AND
CONCLUSION
4.1 INTRODUCTION 69
4.2 GUIDELINE 1: FACILITATING MENTAL HEALTH OF STUDENT
NURSES WHOLISTICALLY: BODY, MIND AND SPIRIT 69
4.2.1 Orientation in clinical placement 71
4.2.2 Preceptor visibility in clinical areas 71
4.2.3 Clinical supervision in clinical placement 72
4.2.4 Debriefing session before and after clinical placement 73
4.2.5 Student accompaniment by their clinical nurse educators 74
4.2.6 Management and leadership style 74
4.2.7 Constructive interpersonal relationships 75
4.3 GUIDELINE 2: GUARDING AGAINST COMPASSION FATIGUE AND
PROMOTING MENTAL HEALTH WHEN CARING FOR
INTELLECTUALLY DISABLED PEOPLE THROUGH 76
4.3.1 Self-awareness 76
4.3.2 Taking care of self 77
4.3.3 Peer support groups 77
4.4 GUIDELINE 3: STUDENT NURSES TO DEVELOP RESILIENCE IN CARING
FOR INTELLECTUALLY DISABLED PEOPLE………………………………79
4.5 LIMITATIONS 79
4.6 RECOMMENDATIONS 80
4.6.1 Psychiatric education 80
4.6.2 Psychiatric nursing practice 80
4.6.3 Psychiatric nursing research 80
4.7 CONCLUSION 81
REFERENCE LIST 82
xiii
TABLES
Table 2.1: Strategies to ensure trustworthiness 29
Table 3.1: Themes and categories of lived experiences of student nurses caring
for intellectually disabled people in a public psychiatric institution 37
Table 4.1: Guidelines to facilitate mental health of student nurses caring
for intellectually disabled people in a public psychiatric institution 70
APPENDICES
APPENDIX A: UJ academic ethics committee 92
APPENDIX B: WITS clearance certificate 93
APPENDIX C: Outcome of Provincial Protocol Review Committee……. 94
APPENDIX D: Medical advisory board (hospital) 95
APPENDIX E: Chris Hani Baragwanath nursing college (Approval letter) 96
APPENDIX F: Request to conduct the study 97
APPENDIX G: To the prospective participant 99
APPENDIX H: Permission to conduct a study (consent form) 102
APPENDIX I: Permission to audiotape 103
APPENDIX J: Partial Transcript 104
1
CHAPTER 1
INTRODUCTION, RATIONALE AND OVERVIEW
1.1 INTRODUCTION
In this research, the term „intellectual disability‟ will be used to describe mental
retardation. The terms „mental handicap‟ and „mental retardation‟ are considered
stigmatising, negative and demeaning, and therefore unacceptable. Internationally,
„intellectual disability‟ is the term most frequently used (Baumann, 2007:524).
According to the Diagnostic and Statistical Manual of Mental Disorders V (Machado,
Caye, Frick & Rohde, 2013:10) mental retardation is replaced by the term „intellectual
disability‟ and is defined as a “significantly sub-average general intellectual functioning
resulting in or associated with concurrent impairment in adaptive behaviour and
manifested during the development period before the age of 18”. Section 1 of the Mental
Health Care Act (No 17 of 2002) defines intellectual disability as “a range of intellectual
functioning extending from partial self-maintenance under close supervision, together
with limited self-maintenance skills in a controlled environment through limited self-care
and requiring constant aid and supervision to severely restricted sensory and motor
functioning and requiring nursing care”.
Classification of intellectual disability provides clarity of the severity of the disability and
the level of support that will be required. Intelligence, measured as Intelligence Quotient
(IQ) and adaptive behaviour scales, are both important in diagnosing intellectual
disability (Baumann, 2007:525). Intellectual functioning level is “defined by standardised
tests that measure the ability to reason in terms of mental age and the skills needed for
daily life, such as self-care, safety, communication, social skills, self-direction, academic
and work skills” (Sadock & Sadock, 2009:1137).
Stigmatisation and exclusion of the intellectually disabled people take place because
people respond to the fact that those who are intellectually disabled are different. The
2
difference lies in their challenges, which include suffering and dependency on others
(Crane, 2002:102).
Intellectually disabled people who are institutionalised, are mostly characterised by
being abnormally active, irritability, aggressive behaviour, emotional instability, repetitive
and stereotypic motor behaviours and self-harming behaviours (Sadock & Sadock,
2009:1173). These are challenging behaviours which may directly affect the mental
health of those who care for them. Student nurses show remarkable symptoms of work-
related stress when caring for intellectually disabled people in a public psychiatric
institution. Student nurses need to be prepared to care for patients with long-term
challenges such as intellectual disabilities. Intellectually disabled people require a caring
relationship that enables an enhanced conscious awareness of life and health
experiences. This relationship facilitates health and healing processes as it involves
trustworthiness and genuine needs of patients (Berg & Danielson, 2007:500).
1.2 BACKGROUND AND RATIONALE
A public psychiatric institution is obliged to provide quality health care service as set out
in the Constitution of the Republic of South Africa (Act 108 of 1996). Quality health care
services includes a high standard of service delivery, an effective institution, and a high
standard of patient care provided by motivated, caring, professional staff. However, for
this to be a reality, student nurses need to be emotionally prepared to deliver such
service in an often extremely demanding and stressful environment. The Bill of Rights in
the Constitution of the Republic of South Africa (1996:11) state that everyone has the
right to an environment that is not harmful to their health. In this study the focus is the
mental health of student nurses caring for intellectually disabled people in a public
psychiatric institution.
Mental health refers to the actual state of physical, mental, psychological or emotional
health of individuals as affected by societal factors. The overwhelming impact of work
on an individual‟s mental health cannot be disputed (Gold & Shuman, 2009:44).
Donnelly, Eburne and Kittleson (2001:4) state that the mental health dimension of
3
human health is called the psychological, reasoning and intellectual dimensions. Bergh
and Theron (2012:364) propose a shift in the focus on mental health from viewing
health as the absence of illness, to health as a complete state and more than mere
absence of illness or infirmity. The Complete State Model of mental health and mental
illness by Bergh and Theron (2012:365) define mental health as a complete state
consisting of the absence of mental illness, or psychopathological disorders and the
presence of a high level of well-being. Additionally, mental illness is defined as a
syndrome that combines the symptoms of low level emotional, psychological, and social
well-being, as well as the diagnosis of a recent mental illness. Bergh and Theron
(2012:373) state that mental health is reflected in patterns of perceptions, logic, thought,
speech, action and emotional response, whether consciously or unconsciously
determined, that reflect personal and extended self-respect and personal and self-
affirmation.
The form of abnormal behaviour which is associated with emotional distress, inability to
function, is called „psychological maladjustment‟ (Bergh & Theron, 2012:372). It involves
the individual‟s thoughts, perceptions, feelings, attitudes, behaviours and interactions
that might affect personal effectiveness and happiness. In the work context, an
individual must learn a productive role or acquire a positive work attitude that will
eventually characterize the work personality which is a semi-governing area of
personality (Bergh & Theron, 2012:373-4).
The meaning and psychological effect of work are complex. Many people have an
attraction and repulsion relationship with their work due to positive and negative aspects
and psychological effects associated with any work situation. However, work can also
be a source of stress and frustration (Gold & Shuman, 2009:45). Too much work, poorly
defined responsibility, lack of support, lack of control and many other factors, can
substitute stressor that, under the right conditions can, in turn, create sufficient strain to
the extent that a person become physically or mentally ill (Thomas & Hersen, 2002:7).
Nursing staff comprise the majority of health professionals in a public psychiatric
institution and spend the most time with patients. Lewis and Stenfert-Kroese (2009:357)
state that attitudes of nursing staff towards caring for intellectually disabled people are
4
of paramount importance, given the potential for negative perception to affect the quality
of care delivered. Nursing is a challenging and a complex job. The work is exciting,
rewarding, exhausting, and also heart-breaking as nurses work with people who are in-
depths of suffering (Eby & Brown, 2005:30-45). All these aspects can negatively affect a
student nurse caring for intellectually disabled people in a public psychiatric institution.
Negative emotions affect the balance of the mind and predispose one to mental illness.
The study by Bakker and Demeroutti (2007:309) state that jobs demands, such as high
work pressure, emotional demands and unclear roles, lead to stress. Job demands may
include physical, psychological, social or organisational aspects of the job that requires
sustained physical and psychological efforts or skills, and which are associated with a
physical and psychological cost, for example, unfavourable physical environments, and
emotionally demanding interactions with clients, in this study, the intellectually disabled
people. Freeburn and Sinclair (2009:335) describe stress as a natural phenomenon that
everyone experiences at some point in life, and it has been noted as a difficult and
complex concept associated with the internal environment; body, mind and spirit
dimension and the external environment; physical, social and spiritual dimension. It has
a potential significant impact on educational performance and the mental health of
psychiatric student nurses. If an individual does not cope successfully, deterioration of
health occurs, whether physically or psychologically. Brown and Edelman (2000:857-
858) identified that, in the absence of appropriate support, lowered self-esteem, and
negative emotions develop. Negative attitudes by student nurses are influenced by a
lack of knowledge and understanding (Guillet, 2002:49). Lewis and Stenfert-Kroese
(2009:356) state that there is link between the attitudes of student nurses and the
quality of care received. Janse Van Rensburg (2009:2) agrees that student nurses
experience emotional discomfort while working with intellectually disabled people. She
also stated that the environment is a challenging context that makes adjustment difficult
for student nurses.
The study could bring light to lived experiences of student nurses caring for intellectually
disabled people, and it will allow the researchers to identify the challenges faced by the
student nurses, their coping mechanisms, and assist in describing guidelines to facilitate
5
their mental health in caring for intellectually disabled people in a public psychiatric
institution.
1.3 PROBLEM STATEMENT
Student nurses at a specific nursing college in Gauteng are placed in a public
psychiatric institution where intellectually disabled people are institutionalised.
Intellectual disability is a lifelong condition and management must constantly be
adapted to satisfy the needs of the individuals affected. Student nurses have difficulty in
coping while caring for these people. Koskien, Mikkauen and Jokinen, (2011:622-628)
state that the clinical experience can impact either positively or negatively on student
nurses‟ personal and professional growth, and the student nurses, mental health is
compromised as they lack knowledge and skills to care for people with intellectual
disability, their conditions, behaviours, unhygienic environment and over-population.
When student nurses are allocated to care for intellectually disabled people in a public
psychiatric institution, I observed that they show a remarkable change in behaviour, for
example nervousness, sadness, fear and multiple physical complaints such as
headaches, fatigue and lack of motivation. This in turn leads to tardiness and a high rate
of absenteeism. In light of this, the researcher then asks the following questions:
What are the lived experiences of student nurses caring for intellectually disabled
people in a public psychiatric institution?
What guidelines can be described to facilitate the mental health of student nurses
caring for intellectually disabled people in a public psychiatric institution?
1.4 RESEARCH PURPOSE
The purpose of the study was to explore and describe lived experiences of student
nurses caring for intellectually disabled people in a public psychiatric institution and to
6
develop guidelines to facilitate mental health of student nurses caring for intellectually
disabled people in a public psychiatric institution.
1.5 RESEARCH OBJECTIVES
The objectives of the study were to:
Explore and describe lived experiences of student nurses caring for intellectually
disabled people in a public psychiatric institution; and
Develop and describe guidelines which will facilitate the mental health of student
nurses caring for intellectually disabled people in a public institution.
$
1.6 PARADIGMATIC PERSPECTIVE
The researcher accepted the Theory of Health Promotion in Nursing (University of
Johannesburg, 2010:9) because the theory‟s purpose is aimed at the promotion of
mental health of the individual, family, group and community.
According to Brink (2009:22) paradigms are models or frameworks that help
researchers to be organised in their thinking, observing and interpreting process. The
paradigm frames the way in which disciplines concerns are viewed, and the direction
that the research project takes. Paradigms are assumptions acceptable and appropriate
for the topic of interest, and must use methods consistent with that paradigm. The
paradigmatic perspective of this study was based on the Theory of Health Promotion in
Nursing (Department of Nursing Science, University of Johannesburg, 2010:9).
1.6.1 Meta-theoretical assumptions
The context of this research is psychiatric nursing. The researcher is guided by the
Theory for Health Promotion in Nursing (University of Johannesburg, 2010:4) as a
theoretical framework. Meta-theoretical assumptions are important beliefs that the
7
researcher has about people, the society they live in and their environment.
Assumptions constitute the core beliefs the researcher has about the explanations of
the meta-paradigmatic concepts such as person, environment, mental health and
psychiatric nursing.
1.6.1.1 Person
Within the Theory of Health Promotion in Nursing (University of Johannesburg, 2010:4),
a person is seen wholistically, in interaction with the environment in an integrated
manner. The person in this research refers to the student nurse caring for intellectually
disabled people in a public psychiatric institution (University of Johannesburg, 2010:4).
Student nurse embody dimensions of body, mind and spirit and functions in an
integrated, interactive manner with the environment, that is, public psychiatric institution
where the intellectually disabled people are cared for.
1.6.1.2 Mental health
Mental health is a state of well-being in which every individual realises his or her own
potential, can cope with the normal stresses of life, can work productively and fruitfully,
and is able to make a contribution to his or her own community (WHO, 2005:5).
1.6.1.3 Environment
Environment refers to the internal and external environment of the student nurse caring
for intellectually disabled people. The internal environment consists of the dimensions of
body, mind and spirit, while the external environment comprises the physical, social and
spiritual dimensions. The mental health status is reflected by the dynamic interaction
between the two environments (University of Johannesburg 2010:4-7). The internal
environment of the student nurse caring for intellectually disabled people includes the
anatomical structures and physiological volitional processes of the student nurse. The
spirit of the student nurse includes the relationship with God.
8
The external environment of the student nurse in the context refers to the physical
structure of the public psychiatric institution for intellectually disabled people where the
student nurse works. The social dimension is linked to the human resources, staff
members, and other student nurses. The spiritual dimension includes values and
religious aspects and or activities in the external environment of student nurses caring
for intellectually disabled people.
1.6.1.4 Psychiatric nursing
Psychiatric nursing is a speciality in the nursing profession in which the nurse directs
efforts towards the promotion of mental health, the prevention of mental disturbances,
early identification of and intervention in emotional problems, and follow-up care to
minimise the long-term effects of mental disturbances (Uys & Middleton, 2004:39).
1.6.2 Theoretical assumption
The Theory of Health Promotion in Nursing (University of Johannesburg, 2010:1) was
utilised as the framework for this study. The study was conducted inductively and after
analysing the results it will be contextualised in the literature.
1.6.2.1 Definition of central concepts
Experiences: means knowledge and skills gained through time spent doing a job or
activity (MacMillan, 2002:482). In this study the term refers practical contact with
observation of facts, events, knowledge or skill gained overtime.
Student nurse: is a learner registered for a four year course leading to registration
as a comprehensive, (general, psychiatry and community) and midwifery according to
the South African Nursing Council, Regulation R425 of the 22 February 2005 as
amended, and function under the supervision of a registered nurse. In this study, a
student nurse refers to a fourth year student who has cared for intellectually disabled
people in a public psychiatric institution.
9
Caring: according to Jooste (2010:6) caring relates to beneficence or helping, and in
this study it relates to the reduction of suffering and the fostering of growth and
development of a human being in suffering.
Intellectual disability: is defined as “a range of intellectual functioning extending
from partial self-maintenance under close supervision, together with limited self-
protection skills in a controlled environment through limited self-care and requiring
constant aid and supervision to severely restricted sensory and motor functioning and
requiring nursing care” (Mental Health Care Act no 17 of 2002).
Public psychiatric institution: is a hospital specialising in the treatment of serious
mental disorders. In this study it refers to health establishments, centres,
organisation, units or part there-of, which is devoted primarily to diagnosis, treatment,
care, rehabilitation or detention of the intellectually disabled people (Mental Health
Care Act no 17 of 2002).
1.6.3 Methodological assumptions
In this research, the Botes model (University of Johannesburg, 2010:9) for research in
nursing was utilised. Methodological assumptions refer to effective scientific practices
with a specific paradigm. According to this model an interrelated relationship exist
between practice and research, which is associated with the fact that research themes
stem from practice and research aims to develop an action-oriented description in a
specified context to improve nursing practice.
A qualitative, exploratory, descriptive and contextual research design was used in this
research. A phenomenological approach was used to explore and describe student
nurses‟ lived experiences of caring for the intellectually disabled people in a public
psychiatric institution. It is envisaged that the guidelines generated in this research will
contribute to the facilitation of the mental health of student nurses caring for
intellectually disabled people.
10
1.7 RESEARCH DESIGN AND METHOD
1.7.1 Research design
In this study a qualitative, exploratory, descriptive and contextual research design was
followed. The research design was described in full in Chapter 2.
1.7.2 Research method
The research was conducted in two phases. Phase one focused on exploring and
describing lived experiences of student nurses caring for intellectually disabled people
in a public psychiatric institution. Phase two focused on developing and describing
guidelines that will facilitate mental health of student nurses caring for intellectually
disabled people in a public psychiatric institution.
1.7.2.1 Phase 1: Exploration and description of student nurses’ lived experiences
caring for intellectually disabled people in a public psychiatric institution
A phenomenological approach was used. In phase 1 the population and sample, data
collection and data analysis were discussed.
a) Population and sample
The available population for this study is student nurses who has cared for intellectually
disabled people in a public psychiatric institution. Student nurses were purposively
sampled to participate in the study. The sample size depended on saturation of data
which occured when additional sampling provided no new information (Grove, Burns &
Grey, 2013:361).
11
b) Data collection
A phenomenological approach was used. The purpose of a phenomenological approach
was to describe experiences as they are lived (Grove et al, 2013:54). Individual in-depth
interviews were conducted to collect the lived experiences of student nurses caring for
intellectually disabled people in a public psychiatric institution. Individual in-depth
interviews are appropriate for exploratory studies as they are conducted like normal
conversations and more free-flowing (Brink, 2009:152). The following central question
will be posed to all participants:
“How was it for you to be working at this institution?”
Unstructured observations, which involve spontaneous observation and recording what
one sees with minimal planning (Grove et al, 2013:508) were used. Facilitative
communication skills such as clarifying, reflecting and summarising were used during
interviews to explore more lived experiences of student nurses caring for intellectually
disabled people in a public psychiatric institution. Each interview was approximately 40-
60 minutes and was audio-taped. Other methods of field notes such as theoretical
notes, methodological notes and personal notes were also included (Bothma, Greeff,
Mulaudzi & Wright, 2010:49-50).
c) Data analysis
The process of data analysis involves making sense out of text and image data
(Creswell, 2013:198). In this study, thematic analysis was utilised. Thematic analysis is
a method for identifying, analysing and reporting patterns within data (Clarke & Braun,
2007:71). The following steps of thematic analysis were followed, familiarising oneself
with the data, generating initial codes, searching themes, reviewing themes, defining
and naming themes, and producing a report (Clarke & Braun, 2007:80). A consensus
discussion about the data analysis was with an independent coder, an experienced
person in qualitative data analysis.
12
d) Literature control
Literature control was used as a verification measure of the research results. The
results derived from data analysis are compared with any existing literature (Morse &
Field, 2002:117). By doing a literature control, the researcher demonstrates that she
knows what work exists in her research topic, gathers and reads subject-specific
material, can analyse and comment on existing work, and understands to what extent
her proposed work is unique (Morse & Field, 2002:117).
1.7.2.2 Phase 2: Description of guidelines to facilitate mental health of student
nurses caring for intellectually disabled people in a public psychiatric institution
Data collected in Phase 1 was used to describe guidelines to facilitate mental health of
student nurses caring for the intellectually disabled people in a public psychiatric
institution. Relevant literature was used to support the results from Phase 1.
1.8 MEASURES TO ENSURE TRUSTWORTHINESS
Trustworthiness was ensured by using Lincoln and Guba‟s model (De Vos, Strydom,
Fouche & Delport, 2011:419) to ensure rigour in qualitative research. Rigour is defined
as striving for excellence in research through the use of descriptive, scrupulous
adherence to details and strict accuracy (Burns et al, 2013:720). In this research the
following criteria for trustworthiness was applied, that, is, credibility, transferability,
dependability and confirmability.
1.8.1 Credibility
Credibility refers to the ability of the researcher to carry out an investigation in such a
way that the truth value of the data and conclusions of the study are established
(Woods, 2000:168). Credibility criteria include prolonged engagement, triangulation of
different methods of data collection, peer evaluation, member checking and authority of
the researcher.
13
1.8.2 Transferability
Transferability is when data saturation occurs and the extent to which the findings from
data can be transferred to other settings (De Vos et al, 2011:420). Transferability
includes dense description of the results with direct quotations from participants‟
interviews, and a complete description of the demographic data. A purposive sampling
of student nurses who has cared for intellectually disabled people in a public psychiatric
institution was nominated.
1.8.3 Dependability
Dependability is whether the research process will be logical, well documented and
auditable (De Vos et al, 2011:420). Measures have reliability when they are consistent
(Creswell, 2013:190). Here the emphasis was on whether the findings would be
consistent if the inquiry were replicated with the same participants or in a similar
context. Dependability criteria include dense description of the methodology, audit
strategies, code-re coding procedures and peer evaluation.
1.8.4 Confirmability
Confirmability is the objectivity or neutrality of the data (Mateo & Kirchhoff, 2009:151).
Neutrality is the extent to which the findings of the study are free from bias. Neutrality
also promotes the acceptability of the study by others as worthy. The researcher
approached the study and entered the field without subjectivity or set ideas. The criteria
for confirmability include triangulation, reflexivity and an audit trail. The researcher
intends to keep memos, as well as observational and field notes to comply with the
above-mentioned criteria.
Trustworthiness will be discussed fully in Chapter 2.
14
1.9 ETHICAL CONSIDERATIONS
Before the study commences, approval was obtained from the institution where the
student nurses are working. This is to protect the participants by assessing the level of
risks the study might pose to them. Approval of this research was also requested from
specific ethical committees, namely the Higher Degrees and Academics Ethics
Committees of the University of Johannesburg and the University of the Witwatersrand
Human Research Ethics Committee.
In this research the four principles stated by Dhai and McQuoid-Mason (2011:14-15),
namely autonomy, beneficence, non-maleficence and justice, were adhered to. The
principle of autonomy takes into consideration self-determination and is the basis of
informed consent and respecting confidentiality. Participants have the right to decide
whether or not to participate in the study.
Student nurses were informed about the proposed study, and their decision to either
participate in the study or not to participate, were respected. Participants could also
withdraw at any time should they wish to do so, without being penalised. Burns et al
(2013:198) state that the process of ensuring confidentiality refers to the researcher‟s
responsibility to prevent all data gathered during the study from being divulged or made
available to any other person. Information shared is only to be accessible to the
research team. The researcher gave each participant a code word or number to protect
his or her anonymity. The participants‟ permission was requested to audiotape the
interviews and they were given consent forms to sign. Audio-tapes will be kept under
lock and key and will be destroyed two years after publication of the results. Only the
supervisors, researcher and the independent coder will have access to the data of this
study.
Dhai and McQuoid-Mason (2011:14) define the principle of non-maleficence as avoiding
harm or doing as little harm as possible. The researcher conducted interviews
individually, in a private office, in order to prevent discomfort and to promote
15
confidentiality. In case of emotional discomfort, the researcher reassured the participant
and arranged debriefing when necessary.
The principle of beneficence requires the researcher to act in the interest of the
participants and to aim at promoting their positive welfare (Dhai & McQuoid, 2011:14).
The researcher carefully structured questions and monitored signs of distress among
the student nurses, since emotional discomfort may occur when describing their
experiences. The study will assist in formulating guidelines for student nurses caring for
intellectually disabled people and to promote their mental health and professional
growth.
The principle of justice holds that each person should be treated fairly and with respect.
The participants of the study were selected and treated fairly by the researcher.
Appointments and terminations were agreed upon. Activities and procedures were not
be changed without the participants‟ consent. Participants were selected for reasons
directly related to the problem and purpose of the study (Grove et al, 2013:198).
1.10 CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS
The necessary conclusions and recommendations were made at the end of the study
with reference to what the research has contributed. Shortcomings as well as measures
to overcome shortcomings were addressed.
1.11 DIVISION OF CHAPTERS
This research is divided into sections listed below
Chapter 1: Background and Rationale.
Chapter 2: Research Design and Method.
Chapter 3: Results and discussions of results.
Chapter 4: Guidelines, Limitations, Recommendations and conclusions.
16
1.12 SUMMARY
The aim in this chapter was to give an overview of the study to be undertaken. In this
Chapter, the background and rationale of student nurses caring for intellectually
disabled people in a public psychiatric institution, was fully discussed. The problem
statement, research questions, purpose and objectives of the study were clearly
outlined. Measures of trustworthiness and ethical principles were also discussed. In
Chapter Two, an in-depth description of the research design and method will be
discussed in detail.
17
CHAPTER 2
RESEARCH DESIGN AND METHOD
2.1 INTRODUCTION
In Chapter 1, an overview of the research study was discussed and in this chapter, the
research design and method used within this study will be outlined. It will provide an in-
depth discussion of the researcher‟s role, measures to ensure trustworthiness, data
collection and analysis.
2.2 RESEARCH DESIGN
A research design is a blueprint for maximizing control over factors that could interfere
with the validity of the findings (Grove et al, 2013:41). In this study, a qualitative, Burns
et al, 2013:51), exploratory (Grove et al, 2013:359), descriptive (Mateo & Kirchhoff,
2009:132) and contextual (Creswell, 2013:175) research design was utilised to explore
and describe the lived experiences of student nurses caring for intellectually disabled
people in a public institution.
2.2.1 Qualitative research
The research was qualitative in nature. According to Edmonds and Kennedy
(2013:112), qualitative research represents a form of data collection and analysis with a
focus on understanding and an emphasis on meaning. It is a method for examining
phenomena, predominantly using „words‟ for data. Marshall and Rossman (2011:91)
also state that for qualitative studies, context matters. Grove et al (2013:51) agree that
qualitative studies are based on a wholistic worldview that there is no single reality, and
reality based on perspective is different for each person, changes over time and has
meaning only within a given context. Where thoughts, feelings, beliefs, values and
assumptions are involved, the researcher needs to understand the deeper perspective
that can be captured through face-to-face interaction and observation in the natural
setting (Marshall & Rossman, 2011:91).
18
Creswell (2013:175) summarises qualitative research as follows: the research takes
place in a natural setting, information is gathered by actually talking directly to the
participants and seeing them behave and act within their context. Participants are the
ones who are knowledgeable about the phenomena (Grove et al, 2013:80), in this
study, student nurses who had cared for intellectually disabled people in a public
psychiatric institution.
The strategy is a road map, a proposed plan for understanding a systematic exploration
of the phenomenon of interest. In-depth interview strategies stipulate a primary data
collection method: interviewing (Marshall & Rossman, 2011:94). In qualitative studies, a
researcher approaches reality from a constructivist position, which allows for multiple
meanings of individual experiences (Creswell, 2013:175).
A qualitative approach is chosen by the researcher so that a wholistic picture of the
lived experiences of the student nurses caring for the intellectually disabled people in a
public psychiatric institution can be obtained and understood. The researcher entered
the field of the research without any preconceived ideas, that is bracketing and intuition,
focusing on the specific phenomena that is being investigated (Brink, 2009:11). The
researcher was the key instrument and collects data herself through observing
behaviour and by interviewing participants. Purposive or judgemental sampling was
used by the researcher to meet people who will provide a rich description of the whole
phenomena that identifies the essence of their lived experiences of caring for the
intellectually disabled people in a public psychiatric institution.
2.2.2 Exploratory research
Exploratory research is the first stage of the research project that gives a researcher
new knowledge about the phenomenon, to be able to design a more in-depth study
(Grove et al, 2013:359). It is where the researcher has an idea or has observed
something and seeks to understand more about it. In this study, the researcher
observed behaviour patterns of student nurses caring for intellectually disabled people
19
in a public psychiatric institution and wanted to explore and find an understanding about
the phenomena.
2.2.3 Descriptive research
Descriptive research attempts to explore and explain while providing additional
information about the topic. It involves the description of specific life events, the
conditions or contextual factors supporting the experiences, the relationship between
individual experiences and the culture the experiences are embedded within, and how
certain life events impact the participant‟s experiences (Edmonds & Kennedy,
2013:130).
It usually begins with a well-defined topic that leads to the research being conducted to
describe the topic accurately (Wysocki, 2004:79). The researcher used individual in-
depth interviews to explore and describe the lived experiences of student nurses caring
for the intellectually disabled people in a public psychiatric institution. Based on the
knowledge generated, guidelines were formulated and described in order to facilitate
mental health of student nurses caring for intellectually disabled people in a public
psychiatric institution.
2.2.4 Contextual research
According to Creswell (2013:175), context means the field at the site where the
participants experience the issue or problem under study. Grove et al (2013:693) define
context as the body, the world, and the concerns unique to each person within which
the person can be understood. This study was contextual in nature as it focused on
student nurses caring for the intellectually disabled people in a public psychiatric
institution. The researcher attempted to understand their lived experiences of student
nurses caring for intellectually disabled people and thus be able to formulate and
describe guidelines in this specific context.
20
2.3 RESEARCH METHOD
The research was carried out in two phases. In Phase 1, the lived experiences of
student nurses caring for the intellectually disabled people in a public psychiatric
institution were explored and described. In Phase 2, guidelines to facilitate mental
health of student nurse caring for the intellectually disabled people in a public
psychiatric institution were formulated and described based on findings from Phase 1.
2.3.1 Phase 1: Exploring and describing lived experiences of student nurses
caring for the intellectually disabled people in a public psychiatric
institution
The aim of Phase 1 was to explore and describe the lived experiences of student
nurses caring for intellectually disabled people in a public psychiatric institution.
Phenomenology is concerned with the study of lived experiences from the perspective
of the individual and this is the approach which was used. A phenomenological
approach is based on the paradigm of personal knowledge and subjectivity, and
emphasises the importance of personal perspective and interpretation (Grove et al,
2013:54). The researcher needed to „bracket‟, laying aside what she knows about the
experience being studied (Brink, 2009:113). Individual, in-depth, phenomenological
interviews and field notes were used to explore the lived experiences of purposively
sampled student nurses.
Phase 1 will be discussed under the following headings: population and sampling,
sampling criteria, data collection and data analysis.
2.3.1.1 Population and sampling
Grove et al (2013:714) describe population as elements that meet the sample criteria for
inclusion in the study. The sample is the portion of population selected consciously to
represent the entire group (Mateo & Kirchhoff, 2009:157). The target population of this
study were student nurses who had cared for intellectually disabled people in a public
21
psychiatric institution. Purposive sampling was utilised. Brink (2009:133) states that
purposive sampling is a non-judgemental sampling. The researcher consciously selects
participants to be included in the study. Student nurses who had cared for intellectually
disabled people in a public psychiatric institution were chosen since they are
knowledgeable about, and have experienced the phenomenon of interest, and were
able to share that knowledge with the researcher.
Sample size was determined by the depth of information that was needed to gain insight
into the phenomena. The number of participants interviewed was based on data
saturation. In a qualitative study, data is adequate when saturation of information is
achieved in the study area, and when additional interviewing of participants provides no
new information (Grove et al, 2013:361). In addition, the authors state that important
factors to be considered in determining a sample size in order to achieve data
saturation include: the scope of the study, a study with a purpose that has a broad
scope will require more sampling of participants than a study with a narrow scope
would, if the topic is clear and the participants can easily discuss it, fewer individuals are
needed to obtain essential data and quality of data. Quality data is best obtained from
articulate, well-informed, and communicative participants (Grove et al, 2013:361).
The sampling criteria include student nurses who:
Has cared for intellectually disabled people in a public psychiatric institution;
Have given consent to participate in the study, as well as to be audio-taped;
Were male and female student nurses;
Expressed themselves in English; and
Were fourth year student nurses.
2.3.1.2 Data collection
Data collection is a precise process of selecting participants and a systematic
gathering of information from participants (Grove et al, 2013:695). Data collection in this
study was described under the headings: in-depth interviews, pilot study, field notes,
and role of the researcher.
22
a) In-depth interviews
The interview is a “managed verbal exchange” and its effectiveness depend on the
communication skills of the interviewer (Ritchie & Lewis, 2003:14), these include the
ability to clearly structure questions, listen attentively, pause, probe or prompt
appropriately and encourage the participant to talk freely and to respond (Clough &
Nutbrown, 2002:134). The researcher needed to have interpersonal skills such as the
ability to establish rapport and trust. In-depth interviews allow individuals to disclose
thoughts and feelings which are clearly private. In-depth interviews are preceded by
observations. The decision to interview implies a value on personal language as data.
Face-to-face interviewing is appropriate where depth of meaning is important and the
research is primarily focused on gaining insight and understanding (Ritchie & Lewis,
2003:138). Open-ended questions were asked to facilitate communication. A central
question: “How was it for you to be working at this institution?” was asked during a
semi-structured in-depth interview of 30 to 45 minutes for student nurses to be able to
relay their experiences about caring for the intellectually disabled people in a public
psychiatric institution. Each interview was audio-taped and transcribed verbatim. The
basic actions that the researcher used during the enquiry process were bracketing and
intuition. According to Brink (2009:113), bracketing refers to the researcher identifying
and setting aside any preconceived beliefs and opinions that she must have about the
phenomenon under investigation. The researcher pursued information of importance
introduced by the participants in this study - student nurses - rather than leading them to
information deemed important by the researcher. Intuition refers to an insight or
understanding of a situation or event as a whole that usually cannot be logically
explained (Grove et al, 2013:5).
The following facilitative skills were used by the researcher:
Active listening: It involves observing the non-verbal messages and being aware of
the participant‟s context within his or her social setting (Fontaine, 2003:58). The
researcher needs to minimise her own responses but show interest by nodding and
23
maintaining eye contact and acknowledging feelings. The researcher needs to listen
to the participants‟ with the sole intention of understanding what they are trying to
express.
Silence: Silence allows the participants to gather their thoughts and think through a
point (Bynum-Grant & Travis-Dinkins, 2010:21). Participants lead the way but the
silence exists to fill the purpose and not make participants uncomfortable.
Clarifying: It is a technique whereby a vague or incomprehensible concept is
addressed. It allows for mutual understanding for both the participant and the
researcher (Bynum-Grant & Travis-Dinkins, 2010:22).
Reflecting: According to Bynum-Grant and Travis-Dinkins (2010:22), reflecting
means questions and feelings are referred back to the participant to allow recognition
and acceptance. It lets the participant know that his/her views are valued. Reflection
encourages participants to become more actively involved. Key words are repeated
by the researcher in order to stimulate the participant to elaborate on, or qualify what
has been said. Reflection helps the participant to focus on feelings and allows the
researcher to communicate empathy (Fontaine, 2003:66). Non-verbal and verbal
messages are repeated for the participants.
Restating: The main idea of what the participant said is repeated, allowing the
participant to make sure that what he/she said is perceived correctly, and letting the
participant either clarify or continue (Bynum-Grant & Travis-Dinkins, 2010:21).
b) Pilot study
Grove et al (2013:44) define pilot study as a smaller version of a proposed study
conducted to refine the methodology. The pilot study tests the practical aspects of the
research study (Brink, 2009:166). Unforeseen problems can arise in the course of a
project. By doing a pilot study, the researcher can recognise and address some of the
problems by obtaining information for improving the project, making adjustment to the
instrument of data collection:
24
To determine whether the proposed study is feasible, that is, are participants
available and willing to participate, time availability, resource availability, and
researcher expertise.
To identify problems with the study design.
To give the researcher experience with the participants and setting.
To identify and recruit participants and obtain informed consent.
To identify outcomes.
To collect data in the form of narratives and write field notes from participants.
The pilot study was done with one participant as a rehearsal before the actual study. It
was important to test the procedure to help the researcher identify problems within the
study and to assist in reflecting on why they might happen, as well as enabling the
researcher to adapt to the method of data collection accordingly (Maltby, Williams,
McGarry & Day, 2010:129).
c) Field notes
Field notes contain the detailed record of the observations made in the field and
constitute the raw data in qualitative research (Sullivan, 2001:340-341). Field notes
provide extensive descriptive detail about the situation the researcher is observing
(Wysocki, 2004:202). They also consist of brief jottings where the researcher makes
notes of something that is happening or something that occurs to them. Field notes are
short and meant to trigger the researcher‟s memory for a later time (Wysocki,
2004:202). Field notes, according to Sullivan (2001:342) included the following
information:
General physical and social setting.
Personal observations where personal impressions and feelings are noted to help
minimize bias by giving a sense of the perspective from which the observer is viewing
various persons or events.
The order in which participants speak.
25
Subjective biases related to the phenomenon.
Direct observations involve the researcher writing notes after leaving the field. The
notes contain detailed, concrete information and sayings from the participants
(Wysocki, 2004:202). The responses are experienced through watching and listening.
Field notes also included theoretical notes, methodological notes, observational notes
and personal notes.
c.i) Theoretical notes
These consist of an integrated set of defined concepts and propositioning that presents
a view of a phenomenon (Grove et al, 2013:527). In this research, the researcher
attempted to identify themes and categories that surface during data collection and was
able to derive meaning from the phenomenon.
c.ii) Methodological notes
Methodological notes refer to any ideas that relate to techniques for conducting the
research in a particular setting. Any difficulties the researcher has in collecting data, any
biases that might be introduced by the data collection technique, or any changes in how
the researcher make and record observations, were noted (Sullivan, 2001:341).
c.iii) Observational notes
Observational data is the raw material an observer collects from observations and
interviews that others have created. Data is recorded as written notes. Observations
capture the whole social setting, the way in which participants interact within the
context, nonverbal communication and observing what does not happen (Grove et al,
2013:508).
26
c.iv) Personal notes
These are written notes that record the researcher‟s personal reactions, frustration and
assessment of events during data collection. The researcher used a diary or journal for
self-reflection.
d) Role of the researcher
In qualitative studies, the researcher is the primary instrument in data collection
(Creswell, 2013:175). The researcher‟s role was to establish rapport and to gain trust
with the participants. The researcher explored the lived experiences of student nurses
caring for intellectually disabled people in a public psychiatric institution using facilitative
communication skills. The researcher facilitated openness during data collection and
analysis and to accomplish this, the researcher needed to set aside personal biases, to
remain objective and not to be easily swayed by the participants‟ emotions.
2.3.1.3 Data analysis
The researcher worked with a wealth of rich descriptive data. The process of data
analysis involves making sense out of text and image data (Creswell, 2013:183). Data
analysis was done concurrently with data collection. In this study, thematic analysis was
used, which is a qualitative analytic method for identifying, analysing and reporting
themes within the data. It minimally organises and describes the data set in rich detail
and interprets various aspects of the research topic (Braun & Clarke, 2007:79). The
authors also state that a theme captures something important about the data in relation
to the research question and represents some level of patterned response or meaning
within the data set. Lived experiences of student nurses were analysed according to
Braun and Clarke‟s guide (2007:83-84) on the six phases of conducting thematic
analysis:
Familiarising oneself with data: this means that the researcher transcribed and read
the data, noting down initial ideas.
27
Generating initial codes: the researcher coded interesting features of the data in a
systematic fashion across the entire set, collecting data relevant to each code.
Searching for themes: codes are collated into potential themes, gathering all data
relevant to each potential theme.
Reviewing themes: checking if the themes work in relation to the coded extracts
(level 1) and the entire data set (level 2), generating a thematic „map‟ of the analysis.
Defining and naming theme: ongoing analysis to refine the specifics of each theme,
and the overall story the analysis tells, generating clear definitions and names of
each theme.
Clear raw data was provided to an independent coder, experienced in qualitative
research, to analyse the data. Thereafter the researcher and the independent coder
met for a consensus discussion and the analysis of the data – the themes and
categories identified.
Producing the report: this is the final opportunity for analysis. Selection of vivid,
compelling examples, final analysis of selected extracts, relating back of the analysis
to the research question and literature, producing a scholarly report of the analysis.
The themes that emerge were discussed with the participants to ensure that the data
obtained is representative of what the participants meant. The literature control was
conducted after identification of themes to identify the research similarities,
differences and contributions, and compared with those of previous research.
2.3.2 Phase 2: Guidelines for the facilitation of mental health of student nurses
caring for intellectually disabled people in a public psychiatric institution
In this phase, the guidelines were described to assist student nurses in caring for
intellectually disabled people in a public psychiatric institution. The guidelines were
drawn in accordance with the themes that were identified in Phase 1 of the research.
The guidelines were discussed with the supervisors and the participants were requested
to comment on and evaluate the guidelines.
28
2.3.3 Measures to ensure trustworthiness
Trustworthiness was ensured by using Lincoln and Guba‟s model (De Vos, Strydom &
Delport, 2011:419) to ensure rigour in qualitative research. Rigour is defined as striving
for excellence in research through the use of descriptive, scrupulous adherence to
details and strict accuracy (Grove et al, 2013:720). In this research the following criteria
for trustworthiness were applied, that is, credibility, transferability, dependability and
confirmability. Table 2.1 is a summary of strategies to be used to ensure
trustworthiness.
2.3.3.1 Credibility
Mateo and Kirchhoff (2009:149) state that there is a need to be confident that the
results are an accurate reflection of the participants and lived experiences that were
studied. There are numerous techniques that can be used to ensure truth value in
qualitative research namely prolonged engagement, flexibility, member checking
triangulation, authority of the researcher and peer examination
Table 2.1: Strategies to ensure trustworthiness
STRATEGY CRITERIA APPLICABILITY
Credibility Prolonged engagement
Reflexivity
Triangulation
Establish rapport by spending time
with student nurses
Creating a context of trust with
student nurses
Field notes were taken
Researcher to reflect on feelings,
thoughts, experiences and
observation
Multiple methods of data collection
29
Member checking
Peer evaluation
Authority of the
researcher
Structural coherence
were used
Literature control was conducted
Use of three supervisors and an
independent coder
Informal member checking was done
during interviews to verify findings
Discussions with colleagues
Study was presented at the peer
research forum
Completed a research methodology
programme and trained in using
facilitative communication skills
The focus throughout study was on
the lived experiences of student
nurses caring for intellectually
disabled people in a public psychiatric
institution
Transferability Realisation of the sample
Dense description of
results
Nominated sample
Purposive sampling
Selection criteria
Direct quotes from participants
Demographic information of
participants was provided
Dependability Dense description of
research methodology
In-depth description of research
design and methods
30
Code-recoding procedure
Dependability Audit
Step-wise replication of
the research method
A consensus meeting with the
independent coder was held after
data analysis
Audiotapes and transcripts will be
kept for two years after publication of
results
Dense description of research design,
methods, data collection and analysis
In-depth description of the research
Confirmability Confirmability audit Audiotapes, transcripts and field
notes will be kept as audit trail
a) Prolonged engagement
The researcher spent sufficient time with the participants to be able to fully understand
their realities and how they describe their lived experiences. Sufficient contact was
necessary to establish rapport with participants to increase their comfort with the
researcher and, consequently, their willingness to share important details (Mateo &
Kirchhoff, 2009:149). The researcher invested more time in fieldwork doing in-depth
interviews until data saturation occurs.
b) Triangulation
Triangulation means the corroboration of information using multiple sources, multiple
methods, different investigators, or even the perspective provided by different theories
(Mateo & Kirchhoff, 2009:149). In this study, the researcher used in-depth interviews
with the participants until data saturation has been achieved and also used theoretical,
methodological, personal and observational notes during the interview with the literature
control to increase credibility.
31
c) Reflexivity
Grove et al (2013:545) refer to reflexivity as critical thinking used to examine interaction.
The researcher reflected on herself as a researcher. The researcher explored her own
background, personal feelings and perceptions to separate them from those of
participants. Field notes were taken during the in-depth interviews.
d) Member checking
The researcher returned to the participants or to subsets of participants and shared
findings with them so that they can verify that the researcher correctly understands
views and lived experiences presented in the interview (Mateo & Kirchhoff, 2009:150).
Discussions were held with the supervisor and co-supervisors on the research method,
research process and literature control.
e) Peer examination
The process provides an opportunity for the researcher to talk through the aspects of
the study with a colleague who is not invested in the study. It helps the researcher
become aware of any potential misinterpretation, missed clues in the data, and personal
value orientation or bias (Mateo & Kirchhoff, 2009:150). The study was presented at the
peer research forum and supervised by three supervisors through the entire research
process.
f) Authority of the researcher
The researcher is a psychiatric nurse who has been trained in interviewing skills,
observational skills and research methods by completing a research methodology
programme. Supervisors are psychiatric specialists and have experience in qualitative
research.
32
g) Structural coherence
The focus was based on the lived experiences of student nurses so as to provide
assistance in coping when caring for intellectually disabled people and data was
integrated in a logical manner. Results gave a wholistic picture of the lived experiences
of student nurses caring for intellectually disabled people in a public psychiatric
institution.
2.3.3.2 Transferability
Essentially it refers to generalizability of data, that is, the extent to which the findings
from data can be transferred to other settings or groups (De Vos et al., 2011:420). The
focus was on confirming that what was meaningful in one specific setting or with one
specific group, is also meaningful and accurate in a different setting or group (Macnee &
McCabe, 2008:172). Transferability criteria include dense description of the results and
nominated sample. A dense description of the results with direct quotations from
participants‟ interviews was provided.
2.3.3.3 Dependability
Dependability is whether the research process will be logical, well documented and
auditable (De Vos, et al. 2011:420). To ensure dependability, the methodology of the
study has been fully described. Hansen (2006:49) state that a clear account of the
research process should be provided to allow the reader to judge the dependability of
the research. The researcher will keep audiotapes and transcripts for two years after
publication of the results.
Dependability can also be enhanced through triangulation. In this research, the
researcher applied data triangulation which involves interviews and field notes as
methods of data collection.
33
According to Mateo and Kirchhoff (2009:151), dependability can be assessed using an
audit trail. In qualitative research, records of all steps in the process of conducting the
study, including procedures, methodological changes that will be instituted, insights that
will be generated during data analysis, and field notes, will be logically and well
documented. These records can be reviewed by other investigators who serve as
auditors to ensure that the processes and procedures are carried out in a rigorous
manner. A consensus meeting with the independent coder was held after data analysis
to confirm themes and categories which emerged.
2.3.3.4 Confirmability
According to Macnee and McCabe (2008:170-171), and Mateo and Kirchhoff
(2009:151) confirmability is the consistency and repeatability of the decision making
about the process of the data collection and analysis. Polit and Beck (2008:539) state
that confirmability includes objectivity between two or more people in terms of meaning,
relevancy and accuracy of the data. Objectivity in this study was ensured by using an
independent coder and supervisors who are qualified and expects in research to
analyse the data. Confirmability was also be enhanced by a confirmability audit. Audit
strategies, like keeping evidence of certain documents such as raw data, field notes and
audio recordings for a period of two years, was adhered to and kept under lock and key
in this study.
2.4 ETHICAL CONSIDERATIONS
The rights of participants were ensured at all times in this research during planning,
implementation, evaluation and during conducting in-depth interviews. The researcher
adhered to ethical principles as described by Dhai and McQuiod-Mason (2011:14-15).
Ethical aspects of this research were fully discussed in Chapter 1. These are principles
of autonomy, non-maleficence, beneficence and justice.
34
2.5 SUMMARY
In Chapter 2 a dense description of the research design and method was presented. A
qualitative, explorative, descriptive and contextual has been selected to discuss the
research question. Measures of trustworthiness and ethical considerations were
addressed. In Chapter 3, the results and literature control were discussed.
35
CHAPTER 3
RESULTS AND DISCUSSION OF RESULTS -LIVED EXPERIENCES OF
STUDENT NURSES CARING FOR INTELLECTUALLY DISABLED IN A
PUBLIC PSYCHIATRIC INSTITUTION
3.1 INTRODUCTION
In this Chapter the research results were presented and discussed according to the
identified themes, categories, concepts and ideas of the student nurses caring for the
intellectually disabled people in a public psychiatric institution. The results of the in-
depth interviews and naïve sketches were described and verified by means of literature
control.
3.2 DESCRIPTION OF THE DEMOGRAPHIC PROFILE OF THE TARGET
POPULATION AND SAMPLE
The target population for this study consisted of fourth year student nurses, of which
four were male and eleven were female between the ages of twenty-five and thirty-five.
These student nurses had already completed their coursework and clinical practical on
intellectually disabled people in their third year. The in-depth interviews were conducted
in English. Ten interviews were conducted with field notes, while five naïve sketches
were collected from student nurses who did not feel comfortable being interviewed.
Sample size was determined by data saturation and the main focus was to obtain in-
depth data from each participant.
All student nurses were interviewed in two male wards in the hospital they were working
in at the time. Offices were provided away from where daily activities were conducted to
avoid disturbances. Informed consent was obtained from each participant before being
interviewed. They were also informed of the use of an audiotape to record the data
which would later be transcribed verbatim.
36
3.3 DISCUSSION OF RESULTS AND LITERATURE CONTROL
The student nurses shared their lived experiences when caring for intellectually disabled
people. These lived experiences were found to be a challenge and eye-opening.
Initially they were shocked by their lived experiences of caring for intellectually disabled
people. Most of them have never been in contact with intellectually disabled people
before. As time passed, some of them started to take part in caring for the people and
even conducted recreational activities. However, before they could fully engage with the
intellectually disabled people, their allocated time at the public psychiatric institution was
complete. The student nurses were of the opinion that one week at the institution was
not sufficient time for the educational teaching they should have received. On the other
hand, most of them did not see their way open to ever returning to the institution to work
there. They were left with feelings of emotional disturbance and sadness, and were not
afforded the opportunity to find closure with regard to their experience.
The nursing personnel seemed to add to their emotional experience both negatively and
positively. From the very first moment of welcoming at the institution, the nursing
personnel influenced their experience. It seems that some of nursing service managers
and unit managers are not fond of student nurses, which contributes to how the
students perceive their experience. Additionally, some of the nursing personnel guided
and taught them about intellectually disabled people, while other staff members were
cruel to the patients and left the student nurses on their own. This, along with a lack of
support from tutors, contributed to their uncertainty and greatly concerned the student
nurses.
It seems that the student nurses were challenged during this period of taking care of the
intellectually disabled people, however they also learnt from this experience.
Below are the results presented in Table 3.1 thereafter a discussion of the results will
follow.
37
Table 3.1: Themes and categories of the lived experiences of student nurses
caring for intellectually disabled people in a public psychiatric
institution
CENTRAL THEME:
The stories of student nurses caring for intellectually disabled people are about
experiencing it as a profoundly unsettling impact on their wholistic being. The
students develop a deep sense of compassion and a new way of looking at life.
Additionally, they experience certain needs while caring for the intellectually
disabled people.
THEMES CATEGORIES
3.3.1 Theme 1
Student nurses experience a profoundly
unsettling impact on their wholistic being
when caring for intellectually disabled
people
3.3.1.1 Student nurses experience that
caring for intellectually disabled people
has an effect on their body, mind and
spirit
3.3.2 Theme 2
Student nurses experience a sense of
compassion and a new way of looking at
life
3.3.2.1 Student nurses experience that
they developed “awareness” while
caring for intellectually disabled people
3.3.3 Theme 3
Student nurses experience a need to
cope while caring for intellectually
disabled people
3.3.3.1 Student nurses experience
educational, emotional and spiritual
needs when caring for intellectually
disabled people
3.3.1 THEME 1: STUDENT NURSES EXPERIENCED A PROFOUNDLY
UNSETTLING IMPACT ON THEIR WHOLISTIC BEING WHEN CARING FOR
INTELLECTUALLY DISABLED PEOPLE
From the data collected, student nurses gave a detailed description of the profoundly
unsettling impact the care of intellectually disabled people had on their wholistic being.
38
Their body, mind and spiritual well-being were affected. According to Dodge, Daly,
Huyton and Sanders (2012:223) mental health constitutes self-governance, competent
in managing the environmental, positive relationships with others, purpose in life,
realisation of potential and acceptance. It also means developing as a person, being
fulfilled, and making a contribution to society. The authors also state that being wholistic
recognises the totality of the human being, the interconnectedness of body, mind,
emotions, spirit, social and cultural relationships, context and environment.
Caring for intellectually disabled people has an impact on the body, mind and spirit of
the student nurses.
3.3.1.1 Body
According to the Theory for Health Promotion in Nursing (University of Johannesburg,
2010:6), the body includes all the anatomical structures and physiological processes
pertaining to the individual. Caring for intellectually disabled people has an impact on
the student nurses‟ physical bodies, resulting in all senses suffering. Senses are unique
and each person has a different way of experiencing normal day-to-day input from their
surroundings (Bergh & Theron, 2012:112).
Specific lived experiences which may affect the physical bodies of student nurses
included strange noises made by intellectually disabled people, unhygienic smells in the
wards, seeing patients‟ deformed bodies as well as the way food was served,
discomfort and uncertainty with regards to physically handling the intellectually disabled
people, and lack of appetite.
a) Experience strange noises made by intellectually disabled people
Student nurses indicated that they felt disturbed by the strange noises made by
intellectually disabled people. Intellectually disabled people are challenged in many
ways due to underdeveloped processes in their brains. They react differently towards
their internal and external environment. Their speech is affected. They are not able to
39
express their wants and needs so it may come out as a scream or laugh or strange
noise. Making loud noises may bring relief and even make them feel good.
Noises made by the intellectually disabled people had a negative impact on the student
nurses. This is supported by the following extracts:
“The sounds they were making…., so these sounds stay in your head even
when you are at home, when you are in a quiet place you still hear these
sounds.”(P02)
And
“It was traumatic to hear the sounds that they were making, it was
unrealistic.”(P08)
And
“Others scream very loudly for no reason, you try to calm them down but
they keep on screaming, you become confused not knowing how to
help.”(P09)
Student nurses got very upset and frustrated by the strange and loud noises made by
the intellectually disabled people in the public psychiatric institution. Unusual sounds
make a person more prone to feeling on edge and to lose concentration. According to
Lombard (2007:17) auditory overload is a very real and known occurrence. It depends
on an individual as to how much noise they can cope with.
b) Experience unhygienic smells in the wards
Due to so many intellectually disabled people being institutionalised, public psychiatric
institutions are overcrowded. Human and material shortages make the situation worse.
The wards are unclean and unhygienic, with some rooms and surrounding areas foul-
40
smelling and covered with faeces and urine. Poor living conditions and human rights
violations are experienced.
Student nurses were negatively affected by the smells that they encountered when
caring for the intellectually disabled people. When bombarded with noxious odours, a
negative emotional response was elicited. This is supported by a student nurse who
said:
“The environment was not healthy and by not healthy I mean the air you
breaths is smell. It is not acceptable to nurse people in such a smelly
environment. (P05)
Another said:
“I am telling you, right from the gate, the place was so smelly, so smelly that
you will think your clothes are affected and they smell. I do not know how to
explain the smell, whether it was faeces and urine and whatever I do not know
but wow… that was bad.”(P10)
And still another said:
“The place was not suitable for nursing people, it was
unhygienic, there were faeces all over the place. The place stinks.”(P10)
The sense of smell affects the way an individual interact with others around him or her.
When the smell-sense is attacked vigorously with unpleasant smells, an individual
responds negatively to others within the environment. Where there are people, there is
more sensory input these lead to sensory overload and when an individual experience
sensory overload, an individual get stressed (Lombard, 2007:21, 89). Student nurses
were exposed to an environment with unhygienic, strange smells which made them
uncomfortable, and since their sensory input of smell was overloaded, it served as a
stressor and they were unable to cope with the smell.
41
Mthembu (2004:9) states that the environment is an important factor influencing the
mental state of a person. The environment is all internal and external factors or
influences surrounding the human being. The influence of the environment on person
can have positive or negative results. A person, as a system, can adapt to the
environment or adjust the environment to suit him or herself.
c) Experience seeing all the deformed bodies as well as the way food was
served
Intellectually disabled people may have physical abnormalities such as a small or large
head, unusual facial features or problems with their feet and hands, scoliosis and joint
contractures. In this study student nurses found out that seeing intellectually disabled
people with severe physical deformities was traumatic and overwhelming. A student
nurse voiced her thoughts as:
“The first ward I entered during orientation was the severely deformed
children, if I may say, I think those ones are the ones that were more
emotionally challenging than the others.”(P08)
Another student nurse said:
“It was for the first time that I saw so many intellectually disabled people,
all those with hydrocephalus, some have deformed limbs. Seeing these
patients I started having diarrhoea. Their limbs were so stiff.”(P02)
And the other student nurse said:
“They were very, very crippled, not merely severe but profoundly crippled
and they could not do anything for themselves.”(P02)
42
According to the study by Van Rensburg (2009:84), the initial experience of caring for
the intellectually disabled people could be described in terms of a confrontation with the
unknown. The confrontation challenged the student nurses by creating intense
emotional discomfort. This is further supported by the following extract:
“It was a challenge meeting those people. It was a challenge in the sense
that you are thrown at a deep end, you know, you read about them in
theory, it was an eye opener how we saw these people. We never thought
that we will see such people in our entire lives.”(P09)
Wong, Chan, Cardoso and Miller (2004:201) state that any new experience, new
encounter or uncertainty can evoke anxiety, and people develop defence mechanisms
to minimise feelings, thoughts and situations that they perceive as dangerous or
uncomfortable. Student nurses experienced varying levels of discomfort and anxiety
when caring for the intellectually disabled people who are different from them in terms of
physical appearance. Student nurses experienced the way food was served to
intellectually disabled people as inhumane. Student nurses elaborated:
“The way they were given food, I mean if you are giving people food, they
have bread and tea or porridge but what they do, they mix bread with
porridge, tea and French polony in a bowl and then feed them. It was not
nice. I felt that it was degradation at its best.”(P01)
And
“The food itself was something else. It was a mixture of all kinds of foods,
bread, tea, cereal and porridge mixed in a big bowl. Probably in there, they
are not regarded as human beings because of the way they are
treated”(P08)
And
43
“Feeding time was very difficult. The food was horrible, yoo!!!, the food
was horrible ( student covering her face with her hand bending over the
table), okay, the food is not horrible per se but the way they prepare it is.
They mix it. In the soft porridge they will put bread, they put the polony in
there, they pour in the tea, mix it up to form a brownish slop and give it to
them. It makes sense that feeding would take a long time if you give one
item at a time but honestly, it was food that you would not give a normal
person to eat. It felt like we were treating them like pigs.”(P10)
Janse Van Rensburg (2009:88) mentioned that there are physical aspects of caring for
the intellectually disabled people, which include any challenges that are related to being
intellectually disabled. It also includes aspects of daily living, such as eating, washings
and elimination.
However, most of the intellectually disabled people, especially those with severe and
profound disabilities require total nursing care. Total nursing care means intellectually
disabled people in a long term facility, who need actual assistance in meeting all needs
in their activities of daily living. With intellectually disabled people, their motor skills,
cognitive skills, speech and social capabilities, are severely limited; they cannot
differentiate between right and wrong. They are unable to take care of themselves and
depend on health professionals to care for them.
Caring for someone is the meeting of the needs of one person by another person,
where face-to-face interaction between carer and cared-for is a crucial element of the
overall activity and where the need is such a nature that it cannot possibly be met by the
person in need him or herself (Held, 2006:32). The needs of the intellectually disabled
people need to be met with dignity and respect, irrespective of their disability.
44
d) Experience discomfort and uncertainty with regard to physical handling
of the intellectually disabled people
Student nurses experienced intense emotional discomfort when caring for the
intellectually disabled people. The discomfort was attributed to perceived lack of skill in
handling these people, even though they received basic theoretical knowledge from
college. Student nurses may be willing to take risks and enter unknown realms as
caring situation demand, but can only do so with the support of others, meaning
registered nurses and nurse educators. The following comments supported this:
“Most of the children had severe contractures. I did not know how to
approach such a situation. We were never given a course to say that if
somebody is like this and you need to attend to him this way.”(P08)
Another student nurse said:
“The people there, the staff were supposed to give us the correct direction
on what to do and not to do to the children, how to stimulate the children.
We were not really taught how to handle this children, how to interact with
these children.”(P02)
And the other one said:
“Because some of them the limbs are stiff, when you put on a jersey, it was
winter when we were there, you have to put on a vest, a top and a jersey on
hands that are immobile…you have to pull, it hurts but with these people
they cannot move and if you pull very hard it hurts but with these people,
they cannot move and if you pull very hard you will break them. You
become frustrated because if you do not dress them they will get cold. You
do not really know exactly what to do next.”(P08)
45
Feelings of discomfort include feeling overwhelmed. The discomfort facilitates the
choice of student nurses to engage on a deeper emotional level with intellectually
disabled people, or to remain distant and aloof (Janse Van Rensburg, 2009:215).
e) Experience lack of appetite
Student nurses experienced affected lack of appetite when caring for intellectually
disabled people. Reduced appetite in the students, especially student nurses, is
sometimes situational stressors. Often it can be difficult to think about food when
suffering from anxiety, frustration and irritability. Student nurses complained of a lack of
appetite while caring for the intellectually disabled people. One student nurse said:
“Some of the student nurses did not eat, they vomit because some of the
patients will defecate and the other will run and take the faeces and eat
it.”(P03)
Another stated that:
“Inside the ward there are faeces all over, it is either you find faeces on top
of the table and at times you find some of the patients trying to eat those
faeces. Thinking of food after being in such an environment was difficult. I
lost weight in one week.”(P10)
And the other student nurse expressed that:
“It was difficult emotionally and physically because we have to take care of
them whether we like it or not. They defecate on the floor and then they eat
it and afterwards they want to touch you with those hands. I could not eat
every time I think about them, that was a terrible situation.”(P09)
Situational stress is associated with psychosomatic complaints, one being a lack of
appetite and weight loss. It occurs when an individual is unable to adjust or cope with a
46
particular stressor. The unhygienic smells in the wards acted as stressors to the student
nurses. The stress usually resolves once the individual is able to adapt to the situation
(Ullrich & Fitzgerald, 2013:1014).
3.3.1.2 Mind of student nurses
The mind is defined as the element of a person that enables him or her to be aware of
the world and his or her experiences, to think, and to feel, the faculty of consciousness
and thought, a person‟s ability to think and reason (http//www.the
oxforddictionary.com/mind). Student nurses‟ ability to think and reasoning was affected.
Their own view on parenthood was affected and they realised the needs of the
intellectually disabled people.
a) Affecting their own view on parenthood
Caring for intellectually disabled people created doubts for student nurses regarding
parenthood and whether they should or should not become parents. The thought of
having a disabled child terrified them. This is supported by the following:
“As a young student, I had so many regrets to be in that place. I even felt
like I do not want to have a child because of the way the staff treated the
children.”(P05)
And then
“It was unsettling in a way (laughing) because you thinking that what if my
child becomes like that.”(P08)
And
“Seeing all those kids, it makes you not to want to have a kid of your
own.”(P09)
47
Being an effective parent is one of the most rewarding tasks in life and it is also one of
the most challenging. Becoming a parent is an overwhelming responsibility of raising
another human being. Effective parenting requires patience no matter the
circumstances (Dinkmeyer & McKay, 2000:1).
b) Realised the needs of the intellectually disabled people
During the period clinical placement, student nurses realised that intellectually disabled
people also have needs. This is seen in the following quotes:
“They need extra, extra care, I mean helping with their diapers, helping
them with feeding, giving them that loving, that special attention.”(P08)
Then
“I think they need more people, I think they need more volunteers to assist
with play time, feeding because they all need that care. Each and every one
of them is different, they all need that special care.”(P06)
And
“The care workers according to my opinion are overworked as those
children need more attention as some of them need to be taken to the
toilet, bathed and fed.”(P04)
The most prevalent problem among intellectually disabled people is the sense of social
isolation and social skills deficit. Improving the quantity and quality of social competence
is a critical part of their care. Physical disabilities, such as speech impairment, visual
impairment, hearing impairment and other medical conditions, may be present and
depending on the severity of the condition, will require full-time care. More human and
material resources are needed to provide the quality care (Sadock & Sadock, 2009:29).
48
3.3.1.3 Spirit of student nurses
Spirit refers to that part of the individual reflecting his or her relationship with God
(University of Johannesburg, 2010:6). It consists of the conscience. Conscience is
defined as the “awareness of moral or ethical aspects to one‟s conduct together with the
urge to prefer right or wrong” (http://www.thefreedictionary.com/preceptor).
In this study, spirit will be related to the struggle with ethical issues arising when caring
for intellectually disabled people, inner conflict and the struggle to see the purpose of
intellectually disabled people‟s lives.
a) Experience ethical issues when caring for intellectually disabled people
Student nurses felt that intellectually disabled people were treated unfairly with regards
to poor quality nursing care. One student nurse commented that:
“One other thing is staffing. When you are there and trying to do all these
things at once, it lead to burn-out because washings and feeding are hectic
on one person… it lead you to become snappy, short tempered and other
nurses become cruel to the patients.”(P08)
Another student nurse reported that intellectually disabled people are being
discriminated against:
“The place is on the outskirts and makes you feel that the
facility is for unwanted.”(P02)
And another student nurse relayed how the intellectually disabled people were treated:
“In terms of the caring itself, you know, at times the patients are beaten.
Here at the facility, there are those boys who their mental state is
questionable but for them to be beaten by some staff members to calm
49
them and to behave in a proper manner….even though they are disabled
they need to be treated fairly.”(P01)
According to O‟Donoghue (2004:81), nursing care of intellectually disabled people is
goal-oriented to provide quality care within a caring environment, as opposed to the
curing environment. The individual should be nursed in a caring and pain-free
environment. Within this environment, nursing personnel should be educated to provide
physical, ethical, moral and spiritual care. In order to provide this physical, moral, ethical
and spiritual care, nursing personnel are required to care for and have respect for the
intellectually disabled. It would be impossible to give quality care if this was against the
value system of the individual. To conduct oneself ethically, an individual must
subscribe to the ethics and norms of society. Intellectually disabled people need to be
respected and to receive quality care.
b) Experience inner conflict when caring for intellectually disabled people
Student nurses were very overwhelmed when caring for the intellectually disabled
people. They felt depressed, scared, anxious, sad and heartbroken. They lost their drive
and motivation to cope with the situation. One student nurse commented:
“The only challenge for me was seeing those people, they broke my
heart.”(P01)
Another wrote this narrative:
“Truly speaking, I do not have that strong heart, I just broke down and
cried in front of those people. ….To think that they will just live the rest of
their lives not knowing how being cared for and being loved feels
like.”(P01)
Another commented:
50
“It was very sad working at that facility, we were traumatised
when working with those children. I do not see myself working there
permanently. I was happy we stayed for one week.”(P02)
Janse Van Rensburg (2009:92) states that situations that contradict one‟s values make
it more difficult to find meaning within a context. She also state that value confrontations
were linked to reflections on why intellectually disabled people were there and what
their purpose was. Different emotions were stirred in these student nurses.
c) Experience that they are struggling to see the purpose of intellectually
disabled people’s lives
Student nurses struggle with the “why” and experience a spiritual crisis. Spiritual crisis is
when an individual experiences drastic changes to their meaning system, that is,
purpose, values, attitude, beliefs, identity and focus because of spontaneous spiritual
experience (Webster, 2002:21). The student nurses were questioning the meaning of
the lives of intellectually disabled people, and could not make sense of it. They asked
themselves why the intellectually disabled people are here in the living world. This is
supported by two student nurses who wrote:
“I personally think that this people are just here to increase the country
statistics, eat and sleep with no purpose in life.”(P01)
And
“We should not have kids like that in life.”(P08)
One other student nurse further commented that:
“I really do not understand why such people live. And to think that they live
longer with all those deformities and all the suffering, even if they are not
aware of the sufferings but other people do.”(P
51
Similarly student nurses questioned the purpose of the intellectually disabled people.
According to Seachris (2013:33-35) people frequently use the word “why” to express a
kind of cosmic complaint or bewilderment. The answer to the question „why are they
here or exist‟ is unknowable. For something to be unknowable, it must be the case that
in principle it is impossible to know it (Seachris, 2013:36).
3.3.2 THEME 2: STUDENT NURSES EXPERIENCE A SENSE OF COMPASSION
AND A NEW WAY OF LOOKING AT LIFE
Student nurses developed “awareness” when caring for intellectually disabled people. In
a study by Berg and Danielson (2007:503-504) nurses formed caring relationships in
brief encounters with patients. The caring problems were experienced as complex,
which demanded space that was not available. Student nurses encountered many
problems at the public psychiatric institution but were aware of what was needed. They
developed a sense of compassion and gratitude. Gilbert (2005:1) states that
compassion, which is an element of loving-kindness, involves being open to the
suffering of self and others, in a non-defensive and non-judgemental way. It also
involves a desire to relieve suffering, cognitions related to understanding the cause of
suffering, and behaviours. Firestone, Firestone and Catlett (2003:23) agree that
compassion is based on the ability to understand another person‟s perspective, that is,
to understand how one would feel if you were that person in any given situation.
Components of compassion include kindness, acceptance, tolerance and love of
humanity. Compassionate people create an aura of friendliness and maintain a
hospitable environment where people realise they are valued. The person giving
compassion grows and in some ways become in tune with the feelings and needs of
others (Gilbert, 2005:39-44).
In this study, compassion is related to a deep level of empathy, awareness of injustices,
awareness of responsibilities of families and communities, and awareness of personal
abilities.
52
3.3.2.1 Experience a deep level of empathy towards intellectually disabled people
and nursing personnel of the public psychiatric institution
Much as the student nurses were overwhelmed at first while caring for intellectually
disabled people, they also developed a deep level of empathy towards these people, as
the following quotes illustrate:
“Yes they are disabled, yes okay they are demanding but at the end of the
day they are human beings”.(P03)
One other student nurse said:
“It broke my heart to think that there is nothing that can be done to help
these people.”(P02)
And the other said:
“Thinking of the suffering all his life that he may have suffered.”(P01)
Student nurses not only developed empathy for intellectually disabled people but also
for the nursing personnel working at the public psychiatric institution. Student nurses
placed themselves in the working environment and conditions that the permanent
nursing personnel are facing every day. One student nurse gave this narrative:
“When I think of it, they have to feed, wash them and do
almost everything for them, play with them, I think they need more
people.”(P03)
She further commented that:
“Staff there are always tired and burn-out, it take a lot of effort to feed, to
take care for these people. If they could really increase the staff because if
53
people are tired, it means they are not giving the care that they should,
what the children need.”(P09)
And another student nurse said:
“The staff was minimal and had a lot of work to do, they are really
overworked.”(P09)
According to Gilbert (2005:51), empathy relates to cognition of another person‟s life
conditions and circumstances. The intellectually disabled people, irrespective of their
mental and physical disabilities, were accepted as human beings by the student nurses,
who would like them to be treated like any normal human beings. In the study
conducted by Janse Van Rensburg (2009:99), a student nurse voiced an attitude of
empathy by saying “I realise as we went along, they are people like us. They are
mentally challenged but at the other hand they are just people like us and they need us
to understand who they are and where they belong.”
The student nurses sincerely cared about what happens to the intellectually disabled
people. Empathy is a major component of the art of nursing. Empathetic nursing care is
to be valued by both the profession and the recipient, in this instance intellectually
disabled people. At first the student nurses interpreted what nursing personnel of the
public psychiatric institution were doing to the intellectually disabled people as
inhumane but they extended the empathy towards them and attributed some of the bad
deeds to shortage of personnel and work overload.
3.3.2.2 Experience an awareness of injustices
Student nurses became aware of the injustices experienced by the intellectually
disabled people and they felt that these people were treated unfairly, not respected,
discriminated against and stigmatised. This is what a female student nurse said:
54
“Now when it comes to washings, it is another story, the way washings are
done, I am not sure if I am allowed to use the word „barbaric‟, it so much
inhumane in a way. The reason I am saying it is inhuman is, they use the
method of a hosepipe from a distance like some animals… the water that
comes from the hosepipe is very cold irrespective of the season of the
year.”(P10)
The other student nurse said:
“The place is short staffed so it is unfair to the patients and harsh because
they do not get the quality care that they deserve.”(P01)
And the other said:
“The facility should not be so isolated, intellectually disabled people also
need to interact with the community.”(P02)
Another added that:
“To me that place is a prison, it is as if they are not accepted in the society
and they just do not fit in, plus that facility is very far and isolated from the
community.”(P02)
The Constitution of the Republic of South Africa (1996:7) states that no person may
unfairly discriminate directly or indirectly against anyone on disability, and everyone has
inherent dignity and a right to have their dignity respected and protected. The move
towards optimal care for intellectually disabled people has been motivated by
encouraging nurses to assume a role in ensuring the best care possible. Held (2006:15)
agrees that the ethics of justice focuses on the question of fairness, equality, individual
rights, abstract principles, and the constant application of them. All people are of equal
value, deserving of basic human rights and dignity. Intellectually disabled people need
to be treated fairly, receive respect and quality care.
55
3.3.2.3 Experience an awareness of responsibility of families and communities
Student nurses were aware that families and communities need to take responsibility to
care for intellectually disabled people. Families and communities need empowerment to
become involved in caring for the intellectually disabled people. This is supported by the
following quotes:
“Institutionalisation is not fair to for the patients, it is better if a patient is
taken care of by family who has love for the child…in the ward, a patient
does not get his personal space.”(P09)
Another one:
“The children need help from the community as well. Volunteers could
really help with the hard work and families could also help out by taking the
users for weekend pass outs.”(N01)
And
“These children are there because their families were unable to take care
for them or not given skills to manage them or they are too busy to look
after. I also think that if these patients can visit their families more to avoid
being institutionalised. Families need to be involved, play a major role in
caring for these children. Families need not dump their children at the
facility. Families take their children to the facility and do not visit
them.”(P04)
According to Bauer and Shea (2003:59), families can and do positively adapt to having
a member with a disability. Social support, a family sense of coherence, and family
adaptability are important resources for family adaptation. After adaptation, families
develop and find external support from work, churches and the community at large
56
3.3.2.4 Experience an awareness of personal abilities
The experiences changed and shaped the personal development of student nurses and
opened doors that they did not know exists. The lived experiences were exciting at
times, worrying, overwhelming and frustrating at other times, but nevertheless it made
them grow professionally and personally. This is evidenced by the following quotations:
“When we go there, we should come back and reflect, ask yourself if you
are matured, have compassion to look after the children, well prepared,
have a clue about the things that we would like to help with, like to have a
goal.”(N04)
One student nurse said:
“The thing is, what I have learnt at the facility is that now I can be able to
counsel people that have conditions like HIV, diabetes because I will tell
them about the children at the facility who have all the deformities and
there is no medication to reverse their conditions whereas HIV and
diabetes have treatment to control as long as you are compliant.”(P08)
And another student nurse said:
“The experience teaches you that such is life and as healthcare workers,
we need to know how to take care of them and would like them to be part of
the community. It is really difficult for them and for us emotionally and
physically.”(P06)
Clinical practice is the core of nursing education during which student nurses are
socialised into the profession. To facilitate optimal learning for student nurses, they
must be presented with a range of real-life work experiences that are presented in a
supportive environment (Nash, Sacre, Calleja & Lock, 2010:669). Knowledge and skills
from qualified nurses and other multidisciplinary team members is transferred to student
nurses during clinical practice. Student nurses also learn from one another. Learning
57
from experience gives one a wholistic integrative perspective on learning that combines
experience, perception, cognition and behaviour (Cross & Israelit, 2000:313). This
enables them to be empowered and to develop personally and professionally in a
caring, collaborative, culturally competent and respectful environment.
3.3.2.5 Experience a sense of gratitude
Gratitude is the quality of being thankful and the appreciation of an inclination to return
kindness (Emmons & McCullough, 2004:4-5). The authors further state that gratitude is
an emotion, the core of which is pleasant feelings about the benefit received. Gratitude
is important not only because it helps someone feel good, but also because it inspires
someone to do good. Gratitude heals, energises and transforms lives (Emmons,
2013:vii).
3.3.2.6 Experience gratitude when caring for intellectually disabled people
Student nurses developed a sense of gratitude in relation to caring for intellectually
disabled people and an awareness of their own opportunities in life. One student nurse
stated that:
“We take for granted the gift of good health, ability to think properly make
decisions.”(N03)
Another said that:
“In life we must appreciate what we have.”(P09)
One further added:
“Working at the facility was an eye-opener in a sense that we take life for
granted, we are healthy and are able to do things by ourselves, we are able
to think.”(N05)
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Gratitude had a tremendously positive value on helping people cope with daily
problems, especially stress (Emmons, 2013:10). Student nurses perceived caring for
intellectually disabled people as stressful, but by comparing their lives with those of
intellectually disabled people, they appreciated what they had. They became grateful for
the countless blessings in their lives.
3.3.2.7 Experience awareness of their own opportunities in life
Student nurses were able to embrace the opportunities of life. They were grateful for the
way life teaches, supports and allows them to realise their potential and appreciate
others. They appreciated the way in which the uniqueness of intellectually disabled
people challenged and stretched their capacity for compassion and wisdom, acceptance
and understanding. One student nurse stated:
“Sometimes life seems so good then you see those people and you realise
now it is not all that good.”(P02)
Another said:
“We should appreciate that we can wake up in the morning and do things
for ourselves.”(P09)
And the other commented:
“For me, that facility was an eye-opening experience, to see another world
of life.”(P01)
The gratitude for what a person give extend to giving to those who are less fortunate.
(Emmons & McCullough, 2004:173). Caring or feeling empathy for intellectually
disabled people causes sympathy, compassion and unselfish tendencies to help.
Gratitude builds and strengthens social bonds and friendship.
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3.3.3 THEME 3: STUDENT NURSES EXPERIENCE A NEED TO COPE WHILE
CARING FOR INTELLECTUALLY DISABLED PEOPLE
Student nurses identified needs to cope while caring for intellectually disabled people in
a public psychiatric institution.
3.3.3.1 Experience educational needs
Student nurses were of opinion that their educational needs were neglected when they
were at the public psychiatric institution. Educational needs include frequent visits of
tutors to the wards, practical guidance during training sessions of how to physically
handle intellectually disabled people and guidance, support and effective role modelling
of the public psychiatric institution‟s personnel.
a) Experience a need for frequent visits of tutors to the ward
Student nurses report that the clinical environment was overwhelming and tutors were
not available to provide support. This is supported by the following comments:
“We were sent there alone. A tutor came once and he did not come to the
wards, we were called to this office and he asked us if we had settled
and left after few hours and that was it, so it did not help much.”(P03)
And the other one said:
“Our tutors need to be always with us to give and support but our tutors
came once to visit us but not stay long and he did not come to the wards,
in one of the offices, so we were left on our own to experience all
these.”(P09)
Another student wrote that:
60
“The tutors only accompanied us once for about 30 minutes. They did not
even go with us to the wards.”(P03)
The findings of Emanuel and Pryce-Miller (2013:19) revealed that particular needs of
student nurses in the clinical environment are not met. To be able to meet challenges in
the clinical environment, student nurses need to perceive themselves empowered and
supported. Clinical empowerment and support are an area where improvement can be
made in order to meet the student nurses‟ educational needs.
Student nurses regarded tutors as a source of support and guidance; however they
were left to rely on ward sisters who also could not offer the guidance, clinical teaching
and supervision necessary due to a heavy workload and shortage of staff. Student
nurses pointed out that they need to be accompanied to clinical areas for support.
Clinical accompaniment is a process whereby a student nurse is accompanied, guided,
supported and comforted by the clinical facilitator in order to become an independent
professional and nurse practitioner (Uys & Meyer, 2005:11). Inadequate
accompaniment in the clinical setting hampers student nurses‟ professional growth and
development, producing inadequately prepared and clinically incompetent professional
nurses to enter the nursing profession with potentially hazardous consequences (Uys &
Meyer, 2005:12).
b) Experience need of practical guidance during training sessions of how
to physically handle the intellectually disabled people
Student nurses experience that they lack knowledge and the skills to physically handle
the intellectually disabled people. They were aware of their shortcomings but did not
have a platform to express their feelings because of inadequate accompaniment. This is
supported by these comments:
“They did not teach us some of their procedures, like during medication,
we did not learn much because someone will be giving you tablets to grind
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without explaining to you as to what is the name of the medication,
what does it do, why are you giving it.”(P10)
Then:
“I did not learn anything, it was so bad for me because they deal with
people that are not like me. We did not know how to approach such a
situation and we were never given a course to say that somebody is like
this and you need to attend to him like this.”(P07)
And
“If you try to ask them to show you a skill or teach you how to handle some
of the patients, they will ask you as to what skill do you want, you are
supposed to have been taught skills at school.”(P05)
Clinical supervision is utilised for creating a safe environment in which a student nurse
can work through the developmental issues or challenges of each level in order to gain
the necessary motivation, autonomy and self-awareness to successfully move to the
next level of development (Huhges & Youngson, 2009:91-93; Jooste, 2010:225).
According to the study by Mabuda (2008:24) it is a challenge for student nurses to apply
theory to practice, because the theoretical content of the curriculum is too idealistic and
academic, and bears little relationship to real needs of clinical practice.
Client care needs should always be met by competent professionals. Competency can
be only be achieved if the person offering care has been educated and taught relevant
information related to duties and activities to be performed in the clinical area (Jooste,
2010:222). Student nurses will not know how to render effective client care in clinical
settings unless they are shown how to correlate the theory they have been taught in
training with real work situations.
62
c) Experience a need for guidance, support and effective role modelling of
the public psychiatric institution’s personnel
Student nurses reported that it was challenging to care for intellectually disabled people
and nursing personnel were not helping in giving them guidance and support. The
institution‟s personnel were also not good role models. One student nurse said:
“The facility was the worst educational institution I have ever experienced
during my four year of study, from management, no professionalism
displayed by the Head of Department.”(P09)
Another one said:
“First day, the sister was not welcoming. She showed us the structure of
the facility and that was all. Then every day we had copy what they were
doing and sometimes they were not treating those children right.”(N01)
And
“No one was allocated to guide us to meet our school requirements.”(P02)
Student nurses learn more effectively in an environment that facilitates learning by
encouraging and supporting, and making them feel they are part of the team (Emanuel
& Pryce-Miller, 2013:19). A reluctance to act as role models and mentors were
observed from the institution‟s personnel, they were always busy.
Institutions cannot afford to admit students and hope that they sink or swim on their own
(Upcraft, Gardener, Bargost & Associates, 2005:39). Instead, institutions need to
understand the need to both challenge and support the students that they admit and
make a commitment to help them succeed.
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3.3.3.2 Experience emotional needs
Student nurses are working in a rapidly changing and stressful environment. They
interact with diverse patients, families, colleagues and other multidisciplinary team
members. They need more emotional support to develop compassionate care. Student
nurses indicated that they need to be prepared before working in a public psychiatric
institution.
a) Experience a need for preparation before working in the institution like
what to expect when caring for intellectually disabled people
Caring for intellectually disabled people was an unfamiliar setting for the student nurses.
Many student nurses experienced stress in the clinical setting because of encountering
severe deformities among the intellectually disabled people, problems with interpersonal
relationships with the institutions‟ personnel, and their performance ability. Student
nurses need to be emotionally prepared to face the situation. This is supported by these
comments:
“I think, we as student nurses need to be emotionally prepared by our
tutors as to what exactly are we going to find in the institution and how to
manage these people.”(P08)
Another student nurse wrote:
“Going to that place is a trauma that I will not forget and I think that it will
be better that student nurses and staff to go for counselling before and
after experience.”(P09)
And
“I think that we needed to have been given a thorough
psychological preparation that where you are going is not a place like a
normal place.”(P10)
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Gaberson and Oermann (2010:49-50) reported in their study that most student nurses
have some anxiety about clinical learning activities and the environment, which hinders
concentration and interferes with information processing and learning. Orientation to
the clinical facility before or on the first day of the clinical placement and nursing
activities, is important. Nursing management of the facility can assist tutors to orientate
the student nurses to help them feel welcome and comfortable in the new environment.
b) Experience a need for group discussions while working in the institution to
ventilate
It was evident from the interviews that the student nurses lacked support from the
institutions‟ personnel and their own tutors. It was also apparent that the student nurses
need support systems of various types in their clinical setting. Student nurses lamented:
“Teachers only came once.”(P09)
Another saying that:
“We were left on our own.”(P05)
And
“The matron and sisters in the wards not friendly, and they were not willing
to helping.”(P02)
Student nurses needed support from anybody else forgetting about themselves as a
group. Group interaction provide personal learning by way of other people through
sharing information, imitating successful behaviour, gaining direct feedback or by direct
suggestions (Ender & Newton, 2000:132). Bergh and Theron (2012:193) define a group
as two or more persons who are united by a common interest. Student nurses were
faced with a challenging situation together and needed to support and comfort each
other. On an emotional level, people gain qualities of support from the group, such as a
65
sense of belonging, respect, caring and hope (Bergh & Theron, 2012:194). A group
setting can also be used for personal growth, self-awareness and changing individual
behaviour.
c) Experience a need for reflective group discussion after working in the
institution
Structured moments for reflection can be helpful in the prevention of disproportional
stress levels, low morals and burnouts experienced by student nurses. The following
comments by the student nurses indicated a need for reflective group discussions:
“It was so hard you become burnout, it lead you to become snappy, short
tempered.”(P08)
“I will never work there. Emotionally it was too draining.”(N02)
And
“We felt so lost and started to feel that the one week we stayed was so
long.”(P04)
Becker (2009:96) states that a student will take a single learning experience and reflect
upon it so that he or she can make it effective, usually by applying the experience to
another challenge, and then by taking an active role in maximising the benefits of the
experience, such as using it as a springboard to the next challenge he or she has set.
Fellow student nurses are an obvious area of support. Student nurses need to have
affection and respectful physical contact with fellow student nurses. They need to be
comforted when they are upset, listened to with sympathy, taken seriously and given
opportunities to share their feelings, including difficult ones like anxiety, fear and
bewilderment. They need to have access to educational opportunities in an environment
that is supportive, that prepare them for the roles of adult life, and in which there are
resources to help them realise their potential (Cowie & Wallace, 2005:5).
66
3.3.3.3 Experience spiritual needs
Spirituality helps you appreciate yourself and the space in which you live, breathe and
work. It helps you understand the decline and flow of life for yourself, others, and the
environment. Spirituality guide beliefs, and beliefs guide action and behaviour (Webster,
202:110). One‟s spirituality beliefs guide how one feels about issues ranging from living
and dying, to understand the meaning of life, to faith and trust. It is wisdom that there is
purpose and meaning even if one cannot see it and do not understand it (Mongelluzzo,
2012:106).
When meaninglessness and futility threaten to overwhelm order and rationality, student
nurses, as human beings in extreme circumstances, need forms of solace (Webster,
2002:112-113). Guidance by a spiritual director on different topics was indicated by
student nurses as a spiritual need when caring for intellectually disabled people.
a ) Experience need for a guidance by a spiritual director on different topics
Why does God allow this?
What is the purpose of these intellectually disabled people?
What is the meaning of life to oneself, and
What is my role or responsibility as a spiritual being, in caring for these people?
Student nurses were sad that the intellectually disabled people were suffering because
of their disabilities. They were perplexed and confounded as to why does God allows
the suffering and meaningless lives of these people. This is supported by these
comments:
“I even pray to God and wondered why He keep such people in these world
to suffer.”(P08)
The other one said:
“We should not have kids like that in life.”(P09)
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And
“These people are suffering for no reason.”(P01)
Spiritual direction or guidance is an interpersonal relationship in which people learn how
to grow, live, and love in the spiritual life (Edwards, 2001:5). Spiritual direction is
important for student nurses because they need to be as spiritually centred and clear as
possible before they can be available to others. Some people seek spiritual direction as
a means of deepening and strengthening the spiritual life they already experience,
some come to spiritual guidance seeking advice about how to provide structure or
discipline in their life, and others come to spiritual direction with a desire to experience a
greater sense of freedom and exploitation (Edwards, 2001:7).
In this study it was evident that student nurses needed spiritual guidance to discuss
what is happening in their lives in relation to God and to strengthen their relationship
with God.
3.4 FIELD NOTES
The researcher experienced difficulties with making appointments with the student
nurses to participate in the study because they were busy with their practical
examinations. The researcher had to wait until they were finished at which time they
were exhausted. Most student nurses appeared anxious at the beginning of the
interviews but they relaxed afterwards and narrated their experiences. Data saturation
was reached after the tenth interview and those who were uncomfortable with interviews
wrote naïve sketches.
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3.5 SUMMARY
The use of in-depth interviews as a method of data collection provided rich descriptions
of student nurses‟ experiences when caring for intellectually disabled people. The
student nurses related their stories openly. It was evident that they experienced
profoundly unsettling impacts on their mind, body and spirit. They also developed a
sense of compassion and gratitude when caring for intellectually disabled people in a
public psychiatric institution. Student nurses have educational, emotional and spiritual
needs that need to be met to assist them to cope while caring for intellectually disabled
people. In Chapter 4, guidelines to facilitate mental health of student nurses while caring
for intellectually disabled people in a public psychiatric institution, will be formulated and
described.
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CHAPTER 4
GUIDELINES FOR THE FACILITATION OF MENTAL HEALTH OF
STUDENT NURSES CARING FOR INTELLECTUALLY DISABLED
PEOPLE IN A PUBLIC PSYCHIATRIC INSTITUTION, LIMITATIONS,
RECOMMENDATIONS AND CONCLUSION
4.1 INTRODUCTION
This study aimed to explore and describe the experiences of student nurses when
caring for intellectually disabled people in a public psychiatric institution. In Chapter 3,
the research results of student nurses‟ experiences of caring for intellectually disabled
people in a public psychiatric institution were discussed and relevant literature
incorporated as to recontextualise results in existing literature sources.
In this chapter, guidelines to facilitate the mental health of student nurses when caring
intellectually disabled people were formulated and described. Limitations,
recommendations and conclusion were also presented. See Table 4.1 as a basis for the
discussion of the guidelines based on the results of Chapter 3.
4.2 GUIDELINE 1: FACILITATING MENTAL HEALTH OF STUDENT NURSES
WHOLISTICALLY: BODY, MIND AND SPIRIT
One of the Theory of Health Promotion in Nursing‟s assumptions is that an individual
functions in an integrated, interactive manner with the environment. It is relevant that
guidelines are formulated based on the promotion of mental health of student nurses in
both the internal and external environment in facilitation of mental health (University of
Johannesburg, 2010:4). For this study it envisaged that clinical educators, preceptors
and psychiatric nurses will assist in facilitating the mental health of student nurses in
clinical placements.
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Table 4.1: Guidelines to facilitate mental health of student nurses caring for
intellectually disabled people in a public psychiatric institution
THEMES AND CATEGORIES GUIDELINES
Theme 1: Student nurses experience
profound unsettling impact on their
wholistic being in caring for
intellectually disabled people
1.1 Caring for intellectually disabled
people has an effect on their body, mind
and spirit
2.Theme 3:Student nurses experience
a need to cope while caring for
intellectually disabled people
Guideline 1: Facilitating mental health
of student nurses wholistically: body,
mind and spirit in caring for
intellectually disabled people
1.1 Orientation in clinical placement
1.2 Preceptor visibility in clinical areas
1.3 Clinical supervision in clinical
placement
1.4 Debriefing session before and after
clinical placement
1.5 Student accompaniment by their
clinical nurse educators
1.6 Management and leadership style in
clinical areas
1.7 Constructive interpersonal
relationships in clinical areas
3.Theme 2:Student nurses experience
a sense of compassion and a new way
of looking at life
3.1 Experience that they developed an
awareness while caring for intellectually
disabled people
Guideline 2: Student nurses to guard
against compassion fatigue in caring
for intellectually disabled people and
the promotion of mental health
through
2.1 Self-awareness
2.2 Taking care of self
2.3 Peer support groups
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Guideline 3: Student nurses to
develop resilience in caring for
intellectually disabled people
Mental health facilitation involves actions that allow people to adopt and maintain
healthy lifestyles and create living conditions and environments that support mental
health. Mental health is the foundation for well-being and effective functioning for an
individual (WHO, 2005:xix). Mental health as a concept reflects the equilibrium between
the individual and the environment. It is evident from the study that the student nurses
caring for intellectually disabled people are experiencing lack of balance in their internal
and external to their environment.
Theme 1 and theme 3 will be discussed under this guideline of facilitating the mental
health of student nurses wholistically.
4.2.1 Orientation in clinical placement
From the results it became evident that student nurses feel lost and unwelcome when
placed in clinical areas. In the study by Twentyman and Eaton (2006:35) student nurses
reported that learning experiences during clinical placements are heavily influenced by
the prevailing culture in the wards. Student nurses feel vulnerable as they face
unfamiliar patients, staff and routines. If student nurses were welcomed, appreciated
and incorporated into the ward team, then the clinical learning experience would have
been considered positive. The main reasons for orientation are to enhance skill and
knowledge of student nurses, to facilitate the integration of theory and practice, and to
ease student nurses transition from college life of books, to the clinical setting
(Charleson, Hayman-White, Ryan & Happell, 2006:25). Orientation to clinical placement
can enhance learning by helping student nurses feel they fit in, by reducing anxiety and
increasing the motivation to learn through early identification of learning outcomes
(Charleson, et al. 2006:26). Student nurses need to be oriented to the work
72
environment, routine, policies, procedures, people that they are likely to encounter, and
the resources available to provide quality care.
4.2.2 Preceptor visibility in clinical areas
Student nurses in this study were beginners who needed a preceptor for support for all
facets of clinical learning. Preceptorship is a short-term relationship between a student
nurse as a novice and an experienced professional nurse who provides individual
attention to the student‟s learning needs and feedback regarding performance, student
experience relative independence in making decisions, setting priorities, management
of time and patient care activities (Burns, Beauchester, Ryan-Krause & Sawin,
2006:173). A preceptor is expected to provide day-to-day clinical teaching while meeting
clinical practice expectations. A preceptor is also expected to have current clinical skills
and knowledge, help students recognise their assumptions and think through their
management decisions, and model effective communication with intellectually disabled
people that emphasises psychosocial aspects of care (Burns, et al. 2006:171-173).
Student nurses learn best when there is ongoing student assessment, close
communication, quick response to student‟s stress, trusting relationships, mutual
respect and acceptance (Sedgwick & Harris, 2012:4).
4.2.3 Clinical supervision in clinical placement
Student nurses need to be mentally healthy in order for them to care for other
individuals. The quality of the working environment is perceived as an important factor
in contributing to the student nurses‟ mental health and well-being and therefore
requires a focus of strategies that reduce stress and promote mental health (Addo,
Stephen & Kirkpatrick, 2012:2). Clinical supervision means assistance and support from
the professional nurse in a clinical facility with the aim of developing a competent,
independent practitioner (Clifton, 2002:36).
Clinical supervision is one of the strategies to prevent adverse effects of stress and
promote mental health of student nurses in clinical placement. Clinical supervision will
73
help student nurses manage the personal and professional demands created by the
nature of their work, especially when they work with people who have complex and
challenging needs. Clinical supervision provides an environment in which they can
explore their own personal and emotional reactions to their work. It will also help ensure
that people who use hospital services and their families, will at all times receive high
quality care from the nurses who are able to manage the personal and emotional impact
of their practice (Clifton, 2002:36).
Clinical supervision focuses on three areas of the student nurse; namely the formative
function, which is concerned with skill development and increasing the student nurse‟s
knowledge. The formative function will help student nurses to reflect with confidence on
their professional role, knowledge and skills as an individual and within a
multidisciplinary team (Sloan, 2006:9). It focuses on enabling student nurses to learn
and develop professional skills and new ideas through receiving feedback. Student
nurses become aware of their strengths and weaknesses in their work (Sloan, 2006:10).
The normative function is concerned with the maintenance and development of
professional standards, ethical and quality practice (Sloan, 2006:10). It focuses on
enhancing the effectiveness and ability of student nurses‟ clinical role and performance
for and within the clinical environment. Clinical supervision provides an opportunity for
student nurses to reflect on complex cases and issues, and the restorative function is
concerned with how student nurses respond emotionally to the stressors of working in a
helping environment and while caring for others. It focuses on building nurturing
supportive relationships that can help reduce stress while providing motivation and
encouragement (Sloan, 2006:11).
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4.2.4 Debriefing session before and after clinical placement
Clinical placements are demanding and stressful, therefore preparation and debriefing
is important in enabling student nurses to emotionally and practically prepare and
disengage from their experience. Briefing and debriefing sessions should be an
expected part of course curricula for where anxieties and expectations of student nurses
need to be addressed to reduce stress and increase confidence (Callister, 2007:10).
Fanning and Gaba (2002:115) defines briefing as orientating a person to an experience,
which includes the instructions, goals and rules within which participants in the activity
can achieve their goals. Debriefing is a one time, semi-structured conversation with an
individual who has just experienced a stressful or traumatic event (Callister, 2007:10).
Student nurses feel less anxious if adequately prepared. The sessions facilitate the use
of therapeutic communication skills and work with the student nurses‟ emotions and
affirm feelings as an integral aspect of learning. Positive feedback from clinical
educators and peers helps to build the confidence of student nurses.
4.2.5 Student accompaniment by their clinical nurse educators
Accompaniment of student nurses is essential for facilitation of the integration of theory
and practice for the effective preparation of future professional nurses (Lekhuleni,
2004:1). Accompaniment of student nurses by their clinical nurse educator will assist
them to integrate the knowledge and skills learned in class and apply it in the clinical
setting. Clinical nurse educators facilitate learning by identifying needs and interventions
aimed towards the development of the student nurses‟ knowledge and skill in clinical
settings. Clinical nurse educators need to avail themselves for student nurses for
simulations, comments, encouragement, praise and assistance in preparation for
difficult and new situations in clinical areas (Lukhuleni, 2004:41-42).
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4.2.6 Management and leadership style
Clinical practice is a period of transition which allows student nurses to consolidate
knowledge and practice skills acquired during fieldwork practice in a working situation.
During clinical placements student nurses are expected to develop competencies in the
application of knowledge, skills, attitudes and values inherent in the nursing profession
(Chan, 2002:69). Learning in the classroom is structured but in clinical placements
student nurses are involved in unplanned activities with patients. Student nurses in this
study perceive clinical experience as anxiety provoking. Clinical placements need to be
conducive to learning for student nurses. A healthy learning environment must be
created to offer student nurses quality learning.
Highly structured clinical settings with rigid task allocation and strict hierarchical
systems are unlikely to meet the learning needs of student nurses (Chan, 2002:70).
Nursing managers in the clinical setting need to adopt a management and leadership
style that create a better working relationship among team members to increase trust
and mutual support amongst members (Booyens, 2009:134-135). Jooste (2009,64) also
emphasises that leadership which is people oriented and focus on human relations and
teamwork, build effective work groups by emphasising the value and dignity of
individuals, and also encourages individuals to assume responsibility for establishing
goals, solving problems, stimulating and guiding student nurses. Communication is
open and trusting, friendly and considerate. Student nurses need to understand what is
expected of them in the work situation.
4.2.7 Constructive interpersonal relationships
Relationships in clinical areas are the most important factor influencing the quality of
placements. Student nurses need to be supported pedagogically and psychologically
(Siggins, 2012:6). Positive working relationships can increase opportunities to practice
in the placement, whereas negative relationships can restrict the student nurse to
routine tasks. A supportive relationship offers student nurses the psychological safety
necessary to ask and respond to questions, make and learn from mistakes. Siggins
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(2012:6) further state that the environment characterised by mutual respect and which is
positive, reduces student anxiety, thereby enhancing cognitive function. Trusting
relationships increase feedback that encourages self-awareness and reflective learning.
Student nurses need to feel respected, appreciated and part of a team.
In the study by Mabuda (2008:27), the author identified the following activities as
constituting a conducive clinical learning environment for student nurses: good
communication with the patients, promoting team spirit amongst staff members,
involvement of student nurses as members of the team, and collective planning to
improve performance. Most negative viewpoints of student nurses regarding the
learning environment were in relation to the staff in the ward. Non-cooperation of the
ward staff was the factor most hindering learning.
4.3 GUIDELINE 2: GUARDING AGAINST COMPASSION FATIGUE AND
PROMOTING MENTAL HEALTH WHEN CARING FOR INTELLECTUALLY
DISABLED PEOPLE THROUGH
Nurses enter the field of nursing with the intent to help others and provide empathetic
care to patients with different needs. Empathetic and caring student nurses can become
victims of the continuing stress of meeting the often overwhelming needs of patients
resulting in compassion fatigue. In this study, student nurses developed a deep level of
empathy for intellectually disabled people. The compassion extended by student nurses
may come with a price when caring for intellectually disabled people. David (2012:64)
state that the nature of psychotherapeutic interventions, including the need for routine
contact with patients and their families, causes a situation where student nurses are
repeatedly exposed to, and share the thoughts, memories and emotional intensity of the
disability, thus rendering student nurses at risk for negative psychosocial
consequences. Compassion fatigue can strike the most dedicated nurses (Mathieu,
2007:1). Student nurses‟ mental health can be promoted through self-awareness, taking
care of themselves and forming peer groups.
77
4.3.1 Self-awareness
Self-awareness is an attribute of emotional intelligence and an important factor in
achieving success. Lombardo and Eyre (2011:4) define self-awareness as having a
clear perception of your personality including strengths, weaknesses, thoughts, beliefs,
motivation and emotions. The process of understanding others begins with
understanding the self. The self has consistent attributes that pervade the way a person
lives and experiences the world. It is the awareness of these attributes of self that
enhance the way a person relate to others. A strong sense of self allows a person to
develop resilience in dealing with the difficulties and complexities of human
communication and experiences (Elder, Evans & Lizette, 2009:6).
When a student nurse develops self-awareness, he or she is able to make changes in
the thoughts and interpretations in his or her mind (Videbeck, 2006:13). With
awareness, student nurses can put a plan of action in place to increase their level of
self-care and ensure that they stay healthy. Student nurses will know how to identify the
warning symptoms of burnout and compassion fatigue and be able to take care of
themselves.
4.3.2 Taking care of self
Student nurses need to take care of themselves wholistically. They need to consider
their needs and put them first to be able to assist others. Lombardo and Eyre
(2011:596) states that, commitment to taking care of one self includes having adequate
nutrition, hydration, sleep, exercises and spiritual practices. Self-care activities will be
unique to personalities, interests and likes. Through self-care, student nurses can have
compassion satisfaction by deriving pleasure from being able to do their work well.
Ashford, LeCroy and Lortie (2002:4) define self-care as a person‟s emotional and
psychological capacity to cope with demands across time, circumstances and settings.
78
4.3.3 Peer support groups
It is evident from the study that student nurses who have cared for intellectually disabled
people, were overwhelmed with caring for extremely physically and mentally disabled
people. Professionally, student nurses need to organise support groups of their own,
whether it be face to face meetings or via email or phone. The group can be small, with
three to four colleagues who meet once a week to debrief and offer support to one
another. Members share the same problem or experience and know that others in the
group understand because “they have been there”. When members share what has and
what has not worked for them, they actually develop a collective wisdom or experiential
knowledge base. According to O‟Brien, Kennedy and Ballard (2008:158-159), members
share the practical coping skills and resource information that they have found helpful in
coping on a daily basis with caring for challenging and complex clients.
4.4 GUIDELINE 3: STUDENT NURSES TO DEVELOP RESILIENCE IN CARING FOR
INTELLECTUALLY DISABLED PEOPLE IN A PUBLIC PSYCHIATRIC INSTITUTION
When student nurses are supported they will be able to develop resilience amid
challenges of caring intellectually disabled people. Stephens (2013:126) maintains that
developing resilience has protective resources such as competence, positive coping
styles, a sense of humour and can connectedness with caring adults. These along with
gratitude and ability to reflect will be the building stones to strengthen resilience in
student nurses in caring intellectually disabled people.
4.5 LIMITATIONS
The presence of the voice recorder made some student nurses anxious when
interviewed. Other student nurses preferred not to be interviewed but wrote naïve
sketches about the stories of caring for intellectually disabled people. The research was
conducted with student nurses from one nursing college in Gauteng. Further research
studies can be conducted in other nursing colleges to gain more understanding about
stories of caring for intellectually disabled people.
79
4.6 RECOMMENDATIONS
4.6.1 Psychiatric education
Clinical nurse educators should be on the programme to accompany student nurses
when in clinical placements, to give support and to facilitate learning. Resources for
briefing and debriefing of student nurses must be made available to promote mental
health.
4.6.2 Psychiatric nursing practice
From the results of the study, it is evident that the student nurses were overwhelmed by
caring for intellectually disabled people in a public psychiatric institution. There is a need
for student nurses to be supported when in clinical placements, to help them cope.
Preceptorship and supervision of student nurses should encourage and promote
learning and facilitate their mental health. According to The Theory for Health Promotion
in Nursing (University of Johannesburg, 2013:4) student nurses‟ mental health must be
facilitated wholistically, body, mind and spirit in interaction with the environment.
4.6.3 Psychiatric nursing research
To improve psychiatric care and nursing practice, research should be encouraged to
promote evidence based nursing. The researcher would recommend that this study be
done again in different contexts involving a larger population of student nurses from
different colleges placed in different psychiatric institutions for intellectually disabled
people. This will improve quality care of intellectually disabled people and create a
conducive learning environment for student nurses.
80
4.7 CONCLUSION
The purpose of this study was to explore and describe the experiences of student
nurses caring for intellectually disabled people in a public psychiatric institution and to
formulate guidelines to facilitate mental health of student nurses. A qualitative,
descriptive, explorative and contextual design was used to conduct the study.
Permission to conduct the study was obtained from various ethics committees, colleges
and from the student nurses who participated in the study. Thematic analysis was used
and an external independent coder analysed the data collected. The independent coder
and the researcher reached a consensus on discussed themes and categories.
Literature review was conducted based on themes identified. The experiences of
student nurses depicted experiencing a profound unsettling impact on their wholistic
being, developing a deep sense of compassion and a new way of looking at life and
experiencing educational, emotional and spiritual needs. Guidelines were formulated to
ensure the promotion of their mental health Recommendations for nursing education,
practice and research were also stated in the research.
81
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APPENDIX A
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APPENDIX B
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APPENDIX C
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APPENDIX D
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APPENDIX E
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APPENDIX F
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APPENDIX G
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APPENDIX H
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APPENDIX I
APPENDIX J
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Researcher My name is Lizzie Simelane and I am a Master student at the University of Johannesburg and I am doing a study about stories of student nurses caring or working with intellectually disabled people in public hospitals. So, how was it for you to be working at this institution?
Participant Personally for me I think it was a challenge. As much as we see intellectually disabled in our community, eh, going there it was eye opening by the fact that there are many disabled people than we think. So, when we went there we heard stories from other students who went there before us, they told us how bad it was but there was no way that you prepare yourself, mmm, when we went there we did the orientation on a Monday, we were shown each ward, they explained about each ward that what it was for. Mmm, the first ward, it was the severely deformed children, if I may say correctly I think those ones are the ones that were more emotionally challenging than the others. Fortunately I was in the ward that was not so bad. The children in there, they were children and adults, they were confined in cotbeds but their brain functioning is still okay, they can talk, it was just the physical deformities and that were the challenges but apart from that they were friendly and if you were blind you would not know that they have a problem. And then with them, in our ward, you can talk to them and they were telling us about their experiences with other students, tell us the things that they like and tell us about other people in the ward. I think, for me knowing that they can do that, it is sort of calming, it shows that it is not that bad because they can have a conservation which is essential and further on, there are younger people, I cannot say children because most of them are teenagers, eh, the younger ones, they do not talk, they are also confined in cotbeds but they play. And further on, like they do not respond when talked to, they do their own things.
R What things?
P Maybe playing with a sheet or with their own hands.
R Please go on.
P Feeding them was a challenge, it was more difficult. So, when I was in my allocated ward, I was wondering about the much more severely, the severe ward that, how are they coping because for us I think the people we are caring for can talk and some can play. There was one who played soccer the whole day, he liked it, so we played with him, we get tired, we swapped, you know, but at least we can see that he is stimulated and he is also reaching out. Other students used to go to other wards for exposure but I could not go, I could not visit other wards, you know, I do not have a child, it was
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unsettling in a way ( laughing) because you start thinking that what if my child becomes like that because some of them had had accidents. There was this child that was born normal but he was involved in an accident and developed cerebral palsy and deformed limbs and then that is it, life changed! Now you know that then, there is nothing much that you can do. And now I am thinking, I do not have a child what if something goes wrong during pregnancy, conception. So, it was very emotional. I will recommend that people go there after they had kids. The other challenge that we had at that place was the washings because some of them the limbs are stiff, when you put on a jersey, it was winter when we were there, you have to put on a vest, a top and a jersey on hands that are immobile, so, when you put clothes on a child that does not want to get dressed, you have to pull, it hurts but with these people they cannot move and if you pull them very hard you will break them. So, that was a challenge, when trying to put those clothes on and you think if you do not do it, it is cold they are human they also get cold, you cannot just decide that it is too much work and leave it, so that was a challenge for me. And with them , you can see the frustration on their faces when you hurt them, when putting on their clothes, they get frustrated, I think they just get bored, you are hovering over them too much.
R Earlier on you talked about feeding that was difficult. What do you mean it was difficult?
P It was the food. The food was horrible, yooo!!!, the food was horrible (student covering her face with her hands, bending over the table). Okay, the food is not horrible but the way they prepare it is, they mix it, in the soft porridge they will put the bread, they put the polony in there, they pour in the tea, mix it up to form a brownish slop and give them. It make sense that feeding would take a long time if you have to give one item at a time but honestly it was food that you would not give a normal person to eat. So, as much as it made sense, it felt like we are treating them like pigs. When you look at their ages, some of them are even older than us. I am 26years old, some of them are older than me but no respect is given to them. So all the food is mashed together so that they can eat, I understand but it is very emotionally challenging. It is also a dilemma because if you do not do it, they would not eat but when you do it, is like you are degrading them at the same time. So, it was very sad, I was not happy working there. The experience teaches you that such is life and as health care workers, we need to know how to take care of them, as much as we would like for them to be part of the community, it is difficult for them and for us. It is both difficult emotionally and physically
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because we have to take care of them whether we like it or not, and them, they get frustrated because they cannot do things for themselves, and the ones that can actually voice their problems can but the ones that cannot just show tantrums, they will scream they will be kicking, and you have to understand that we as students do not understand why these people are behaving like this, they are making our lives difficult but we need to understand that they are doing this because you are irritating them, they just want you away from them. So, I think it is really hard for us. Places like that need patience, we need to involve the community because everything that we have seen, I did not know that there is a place like that, we heard about it at school and when we got there, it was something that I did not expect, for one, that place is secluded the only way you can get there is if you were lost and you suddenly found yourself there. So, if it can be open like other hospitals, it should be known in the first place, it should be accessible, these people should not be taken there where it seems like we are so scared of them, an isolated place. They should get more visitors and seeing their families, they get so happy, like children, they become so happy, you could see that in their body language that they are happy when they have visitors, they smile, jumping around those who can walk, greeting them. The staff there was accommodating knowing that it is a trying situation. They tried to help us, I can speak only about the ward that I was allocated to. They tried explaining to us especially the feeding, why they were doing it that way because we were voicing our concern and they explained that if you do not do it then there is a problem because they would not eat. The security was great because there are up and about children, some are naughty. There was a young boy who could squeeze himself from buglar bars, they ended up ordering mash to be put on all windows and doors to prevent him from going out, he was just not listening to reprimands and you cannot just seclude him in a seclusion room everyday so he need constant watching and there is time that you cannot be watching one person all the time. The security is tight, as much as these people can get out of the ward, they cannot get out of the premises. So, it was very good that they can run around the yard but cannot go outside and get lost. If one can get lost, as I have said that the place is secluded, I do not know what would happen because there are just bushes. All in all, the staff is trying to care for these people. The clothes are
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not that bad, they are not of best quality knowing our public hospitals these days but at least, for that time as I have said it was winter, I was happy to see that all had jerseys, jackets on and the wards were warm, so that was a relief. We spend five days at that place. The first day was very traumatizing, then Wednesday to Friday, I do not know whether it was a relief that we were leaving but it felt better, now you can look at these people without feeling sad, that pity for them because at first you get frustrated, sad, you pity them but now as you get to spend time with them, you realize that, as much as they are so many things that they could not do, they are still human beings. There was a girl that was making jokes all the time, she sits there and laughing, and there are people who are not intellectually disabled but they could not smile at you or be friendly. As much as other people do not have something that other people have, even if these people are mentally challenged, it was a pleasure being with them, and I do not know if I can do it again.
R What do you mean?
P If I have to do it again, I do not know but it takes time, you need to go back well prepared emotionally. The stories that they tell us at college did not prepare us for what we saw there, it is like they scare you with bad expectations but when you get there it was on a different level. So, I think, when we go there, we should come back and reflect and you just look at yourself, ask yourself if you are matured, have the compassion and well prepared, have a clue about the things that you would like to help with, like have a goal. When we were there, we met different children with different problems, you have to go there with a will to help, with a big heart and patience. There was a boy that was eating faeces. Such things are difficult to stop because you find that they are running around and the next thing one is defaecating and you cannot remove the faeces immediately, you cannot run around with them to prevent them eating faeces. There was one incident that we witnessed and in times like this, you know how everybody expect nurses to be perfect, in situation like this , you just do not know what to do (laugh), do you shout at him? Do you, eh, what do you do because basically you cannot just go, you do not have gloves on, so by the time you go and get gloves, where are the faeces? They are already down his throat, if you try to pull him to stop, those faeces will be on you or your clothes. So, it is really a challenge to be caring for the intellectually disabled people. You really need to be
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prepared, they need extra, extra care and by care I mean helping with their diapers, helping them with feeding, giving them that loving, that special attention. One other thing is staffing, I think, I can say they are not enough. When I think of it, they have to feed, wash them and do almost everything for them, play with them, I think they need more people, I think they need more volunteers to assist with play time, feeding because they all need that care, is not like in normal wards where you may have three critically ill patients, a nurse can be allocate to look after them, the rest do not need that kind of care with the intellectually disabled, each and every one of them is different, they all need special care, there is one that plays soccer , the other one talking and laughing and the other one will need something else . When you are there and trying to do all these things at once, it will lead to burnout because the washings and the feeding is hectic on one person. If you have to feed six children who eat very slow, it is hard. So, when you see how tired you are and think of these people on a daily basis, doing these things on a daily basis, it is hard, you become burnout, it lead you to become snappy, short tempered.
R I hear you talking about being burnout. What do you exactly do you mean by being burnout?
P By burnout I mean you gonna get tired, you are going to be irritable, being frustrated and you end up doing things that you are not suppose to do, you end up shouting at these poor people who do not even understand why you are frustrated, it is not like you are doing it on purpose, it will be because you are exhausted. The mixing of all that food and making sure that the food is moist because if the food is not up to standard, they will spit it out, you have to clean them again and again, it takes a lot of effort to feed, to care for these people. If they could really increase the staff because if people are tired, it means they are not giving the care that they should, what the children need. These children are there because their families were unable to care for them or not been given skills to manage them or they are too busy to look after them. I also think that if these patients can visit their families more to avoid being institutionalized. Families need to be involved, play a major role in caring for these children. Families need not dump their children at such places.
R How do you mean dump?
P Families take their children to that, they do not visit. I think they
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need that stimulation from the outside world because something new makes them happy. Sometimes as much as their stories would not make sense to you or may sound stupid, you have to understand that this person cannot differentiate between right or wrong. The thing is, what I have learned at that place is that now I can be able counsel people that have conditions like Hiv, diabetes because I will tell them about the children at that facility who have all the deformities and there is no medication to reverse their conditions whereas Hiv and diabetes have treatment to control as long as you are compliant. For me facility was an eye opening experience, now that I am not there, I can say I enjoyed it, not that I have fun but it was an eye opening experience.
R Anything more to add?
P No
R Thank you for participating.