Feelings and Thoughts of Patients Regarding Activities Conducted by Nurses in a Psychiatry Clinic

Introduction

Mental health is one of the important concepts that is true everywhere and for everyone. As the World Health Organisation emphasized, all over the world, mental health needs are high, but services are inadequate. In addition, examples of good practice and people’s experiences from around the world highlight why and where change is most needed and how it can best be achieved.¹ It is known that increasing the number of nurse-patient interactions and activities for patients in psychiatry services improves clinical outcomes for patients with mental illness.² Considering the inadequacies in the number of beds and health personnel, it causes patients to be discharged without full treatment, nurses not interacting with patients sufficiently and not performing nursing activities.^3,4

The objective of psychiatry clinics today is to help patients become aware of the psychiatric problem causing their hospitalization and recover from it. Therefore, an ideal hospital setting should involve a therapeutic environment that gives the opportunity for patients to use their personal strengths in the best way with the help of social organizations, supportive efforts and social values rather than emphasizing the disease itself.^3,5 The therapeutic environment is an ideal and dynamic environment that aims for the recovery of patients and enables them to return to social life quickly.^6–8 Such a setting can be a real training arena for patients to practice their communication and coping skills that will enhance their social adaptation to the society after recovery.⁹ The goal of a therapeutic setting is to meet patients’ basic needs and to help them improve their self-expression, benefit at the highest level from patient-staff communication, control their problematic behaviours, cope with stress, participate in the management of the unit, improve self-esteem, self-appreciation and self-confidence, become more active in the society at work and in life and improve their interpersonal communication skills with other people.^10,11

A therapeutic setting is an important factor that either decreases or increases the healing effects of other treatment methods used for psychiatric patients.^8,12 In a study, it has been reported in a study made with patients in an acute psychiatry unit that the setting can either increase the severity of the disease or contribute to recovery. They have also reported that the setting continues to be a significant but often neglected component of psychiatric treatment.¹³ Setting up a therapeutic environment is among the standard practices of psychiatric nursing. Being 24 hours with patients in the hospital, nurses are responsible, together with other health professionals, for establishing, structuring and sustaining a safe, therapeutic and recovery-oriented treatment environment.^14,15 Psychiatric nurses have major duties in establishing a therapeutic setting. They are required to set up a therapeutic environment and to conduct various leisure activities.² A study made with patients in a psychiatry clinic in Australia has reported that health professionals have important roles in creating a secure care atmosphere.¹⁶ Sharac et al¹⁷ found that health personnel in psychiatry wards spend at most 50% of their time with patients and do not spare enough time for therapeutic activities. Most of the health personnel used observational methods and found that at best 50% of staff time is spent in contact with patients, and very little time is spent delivering therapeutic activities. A psychiatric nurse should always keep patients in a minimally restricting environment, identify the activities (both individual and group) that meet the physical and mental needs of patients, and encourage them to take part in these activities.¹⁰ The main goal in work and leisure activities, which are part of a therapeutic setting, is to establish cooperation between patients and nurses. In this process, the nurse observes the patient, collects information about the patient, identifies the strong and weak points of the patient, and plans the care together with the patient. The patient is included in the process of planning the nursing care.⁷ While satisfaction of a patient’s physical, mental, emotional, and social needs in a therapeutic setting has favourable impacts on the treatment process, failure to meet all or part of these needs has negative effects on the patient’s recovery status in the treatment process. Therefore, it is very important how the patient perceives the clinical environment.^6,15 An effective and safe therapeutic environment enables patients to accept each other and to participate in the group in a meaningful manner.¹⁸

In a study, almost all psychiatric patients stated that the activities conducted by nurses had a favourable effect on their daily living. For example, a manic patient stated that although he was an impatient person, he learned to be patient and listen to others during these meetings and another patient said “I have this twitch of frequently tossing my head backwards. I learned how to control my twitches in the group”.³ A study made in a psychiatry clinic has shown that psychosocial therapy approaches such as occupation, hand crafts, painting, sports, and good morning meetings led to significant increases in personal and social performance scores in both psychosis and non-psychosis patient groups.¹⁹

In this clinic which was conducted the study in Turkey, good morning meetings, work incentive meetings, morning sports, flower care, movie hour, activity hour (painting, hand crafts), and sweet Wednesday activities are used in psychiatry clinics as work and leisure activities. All these activities are conducted by psychiatric nurses in this clinic. A search of the literature on the feelings and thoughts aroused in patients by such activities carried out in psychiatry clinics revealed that there were very few studies on the feelings and thoughts of patients. Patients’ perceptions of nursing care are very important. Patients’ feelings and thoughts regarding the activities conducted by nurses in psychiatry clinics can be identified and the nursing care plan can be restructured based on these. For this reason, this study is thought to make a major contribution to the nursing literature. This study was conducted for the purpose of revealing the feelings and thoughts of psychiatric patients regarding nursing activities carried out in a psychiatry clinic.

Materials and Methods

Design and Setting

This study was a retrospective, cross-sectional and qualitative study was used with the phenomenological method. Qualitative descriptive studies explore participants’ thoughts, experiences, social processes and working styles in detail²⁰ and offer a comprehensive summary of an event.²¹ The reporting of this study was performed in line with the Consolidated Criteria for Reporting Qualitative Studies (COREQ).²²

With a capacity of 22 beds, the psychiatry clinic of a university hospital where the study was conducted renders services with 6 specialist physicians (faculty members), 8 assistants, 7 nurses, 4 support staff, and a cleaner. Under the responsibility of the nurses, a number of activities (good morning meetings, work incentive meetings, morning sports, flower care, movie hour, painting, hand crafts, and sweet Wednesday) are carried out in this clinic. Written feedbacks are collected from the patients after these activities and are archieved. Providing a written feedback after an activity by a patient is voluntary. No feedbacks are obtained from those patients who do not want to give a written feedback. These written documents do not bear the patient’s name, but only his/her age, gender and medical diagnosis.

Sample

The sample of study consisted of the feedback documents (n=142) written by the patients who were hospitalized for treatment the psychiatric clinic of a university hospital in the south of Turkey. Psychiatric patients who took part and gave written feedback in the activities carried out by nurses between November 2014 and November 2015 by using the purposive sampling method was selected. In the present study, the researchers analyzed the data were obtained by reviewing the entire written documents of the patients (142 written documents) who provided feedback. While determining the sample size in qualitative studies, an approach that requires researchers to continue collecting data until the saturation point is reached is used.²⁰

Data Collection

The four researchers works in the psychiatry clinic where the research was conducted regularly nursing activities. Researchers were regularly filing patients’ feelings and thoughts after nursing activities in the clinic. This filing continued during the data collection dates. After obtaining the permissions of the ethics committee and the institution for the research, the data files containing the feelings and thoughts of the patients were transcribed in the computer environment.

Data Analysis

Data were analyzed by two researchers, who were experts in qualitative data analysis. Sociodemographic data were analyzed using numbers. Data were transcribed verbatim using Microsoft Word and then these data were combined with the observation notes to obtain raw data. Then, content analysis was used to analyze the data. First, each sentence was read several times to understand the text. Next, words or short sentences with a meaning related to the event were given a code and code lists were created for each sentence. Considering the event examined, the similarities and differences between the codes were taken into consideration and the associated codes were combined with categorizing them. Each category was named by its content. Then, by focusing on these categories, themes were formed based on the common relationship among these categories. Analyses were performed independently by two researchers, and researchers reached a consensus on the themes that best described the findings. At the stage of analysis of the obtained data, the raw data were given to two persons who had expertise in their fields and have conducted research on qualitative studies to obtain their expert views.²³

Trustworthiness

The research team consisted of nine female researchers, nurses and academicians (a registered nurse, three master of science, two PhD candidate and one PhD, a associate professor, a professor. All the researchers were trained in qualitative research techniques and had previously conducted qualitative research. Yıldırım and Şimşek²⁰ explained the trustworthiness, credibility, transferability, dependability, and confirmability. Credibility was ensured through patients’ feelings and opinions in the findings section. Also, selection criterion was established to provide data diversity for the diagnosis of the patients.²⁰ For transferability, purposeful sampling was used. For dependability, all nursing activities were conducted by the same researchers. For confirmability, after the nursing activities, the researchers summarized the data obtained from the nursing activities to the patients.

Reflectivity and Reflexivity of Researchers

The reflective and reflexive skills of the researchers facilitated them to use the qualitative research method skilfully and flexibly, to have a critical perspective and to be a part of the process.

Ethical Considerations

Before the study was conducted, ethics committee approval was obtained from the ethics committee (decision no: 2016/182, date: 09.06.2016), and institutional permission was obtained from the institution where the study was to be conducted. All participants were informed about the purpose of the study and individual consents included publication of anonymized responses/direct quotes from the patients were obtained.

Results

Based on the content analysis of the data, three main themes titled “Effect of Activity on Patient”, “Feelings Created by Activity in Patient”, and “Patient Views on Activity” and seven sub-themes were obtained (Table 1). Of the participating patients, 61% were female and the mean age of the patients was 41.47±14.62 (minimum:17-maximum:80).

Table 1 Main Themes and Sub-Themes

Theme 1. Effect of Activity on Patient

Subtheme 1.1. Activities Improve Togetherness with Other Patients, Creation of a Family Atmosphere, and Friendship and Communication

Almost all patients stated that the activities carried out improved friendship and communication and helping each other increased the value given to humans and friendship. These activities carried out together with nurses were found to bring patients closer to each other like brothers and sisters, to establish unity and togetherness between them, to create a peaceful environment and family atmosphere, to decrease the feeling of loneliness, and to promote socialization. Moreover, contrary to increasingly decreased habit of sharing today, it was stressed that sharing increased owing to these activities. The statements of two patients on this subject are given below:

I was kind of stressed, being occupied with works all together was great for me, I am relaxed now. The activities were wonderful in that they brought people closer to each other and enhanced communication, love grows when shared. (Male, 42 years old, Depression)

Although the film we watched did not create a cinema atmosphere, it was nice because of being done collectively, we watched the film all together. (Female, 22 years old, Depression)

Subtheme 1.2. Activities Make Patients to Feel That Health Professionals are on Their Side

The majority of the patients who took part in the study reported that owing to these activities, they always felt that the nurses were on their side, they spent more time with them, for this reason they were understood by the nurses and did not feel alone. The statements of two patients who felt to be understood by the nurses are given below:

Nurses bring us together and they spend time with us during every activity. I’m happy here, every Wednesday many people make cookies together and we eat them together, I know that nurses think about us. Because they are with us, I feel that nurses understand me and want to help me. (Male, 55 years old, Alcohol Dependence)

The nurses prepare, explain trainings for us, for our sake, carrying out trainings shows that nurses care for us. (Male, 49 years old, Anxiety Disorder)

Subtheme 1.3. Trainings Promote Engagement with Life

More than half of the patients participating in the study stated that they did not want to take part in these activities when they were first hospitalized, but after they took part, they had a feeling of relaxation, started doing things that they did not want to do before, their stress eased and all these enabled them better hold on to life. The statements of two patients are given below:

It’s nice that you try to make people embrace life again, these activities give us life enjoyment. (Female, 22 years old, Major Depression)

With these activities, I can slowly begin doing what I want. (Female, 28 years old, Schizophrenia)

Subtheme 1.4. Activities Enable Patients to Acquire Information

More than half of the patients participating in the study stated that they had the opportunity to learn things that they did not know owing to the patient trainings provided, and that these trainings were useful and they gained awareness. The statements of two patients are given below:

Our activity improves our information learning aspect, it eliminates the continuously present negative effects of our ailment at least for a moment. I think the information given during trainings is beneficial. For example, as a person suffering from sleep problems, I got some important information regarding sleep. The training was supported by a slide show and brochures. Therefore, it was quite effective. (Male, 48 years old, Bipolar Disorder)

After the coping with stress training, I recognised my own stress, learned how to cope with it, activities are wonderful, so glad to have you. (Male, 35 years old, Alcohol Dependence)

Theme 2. Feelings Created by Activity in Patient

Subtheme 2.1. Activities Enhance the Feelings of Relaxation, Happiness, Confidence and Being Valuable

All the patients reported that they had very nice and positive feelings after the activities, which made them relax and their stress diminished. The patients stated that they had the feelings of peace, happiness and being valuable after each activity. It was found that owing to the activities the patients had the opportunity of doing and learning things in the hospital setting that they have not done or known about before, and in this way, their self-confidence improved. The statements of two patients are given below:

These activities conducted by the nurses feel like therapy for me. As we have talked with friends, the activities enlighten all of us. They raise confidence in me and our disease and make me confident. It gives the confidence of a family atmosphere. It reminded me of my childhood, my happy days. It makes me feel I am living, life is sharing. I learned a lot from these activities. Every activity we engage in relieve my inner world. (Female, 31 years old, Psychosis)

They slowly give us the courage to be able to do work. Because, I personally was not doing any work at home. The attentiveness of the hospital employees during activities is very nice. Although I didn’t want to do at the beginning, I realized that I could do the activity once I started and I was thinking that this would help me overcome my illness. (Female, 62 years old, Major Depression)

Theme 3. Patient Views on Activity

Subtheme 3.1. Activities are Nice and Delightful

All the patients reported that all activities were good and nice, carefully planned practices, they had pleasant and delightful time, they were happy with the activities, and some of the films watched during the movie hour were humorous and made them joyful. The statements of three patients are given below:

It’s good that the film was a comedy. At least we can laugh. (Female, 61 years old, Anxiety Disorder)

Our poem reading with music activity was very nice. We were happy. We want it to be so joyful all the time. We were full of joy inside out, thank you. (Female, 57 years old, Depression)

Although I came just recently, I was very pleased with the events and activities organized by the nurses. It was very nice, I was pleased to take part in the activities. (Male, 26 years old, Depression)

Subtheme 3.2. Wishes for Continuation of Activities and Thanks

After the activities, all the patients thanked and expressed their wishes for the continuation of all these activities. The statements of two patients are given below:

We want them to be continuous. Owing to the activities, we don’t realize how the time passes. (Female, 36 years old, OCD + Depression)

The sweet Wednesday event was really very sweet, endless thanks. (Female, 25 years old, Anxiety + Depression)

Discussion

The patients stated that these activities carried out with the nurses improved friendship, communication, value given to humans, and sharing. They also stated that these activities brought the patients together like brothers and sisters, created a family atmosphere, diminished feelings of loneliness, and enhanced socialization, unity and togetherness. Individuals with mental disorders may often experience social isolation due to stigmatisation and negative attitudes. It can be said that the activities organized by nurses met the psychosocial needs of the patients such as communication, social acceptance and respect. It is stated that in psychiatry clinics, in addition to individual and group therapies and meetings, occupational activities such as sports and art have an important place in the treatment process of patients.²⁴ In a study, it is suggested that executive music therapy practice reduces the state anxiety levels of psychiatric patients and should be included in activities related to the therapeutic environment.²⁵ In the study of Kamışlı and Daştan,³ regarding the effect of group practices conducted by the nurses in a psychiatry clinic on the daily lives of patients, the patients reported that they made use of their free time owing to these activities (77.8%), started taking responsibilities (70.4%), acquired information (55.6%), developed hand craft skills (48.1%), helped others (37%), and felt themselves in a family atmosphere (33.3%). A systematic compilation study has shown that art therapy reduced the feeling of isolation and anxious thoughts, developed positive feelings and coping skills, increased patient-nurse communication, and had a positive impact on the attitude towards hospitalization.²⁶ In a study, it was reported that the structured exercise program applied to schizophrenia patients in community mental health centers increased the quality of life and sleep of the patients. In addition, it was suggested in the study to use exercise as a complementary method to increase the effectiveness of treatment.²⁷

Patients stated that owing to these activities, they always felt nurses on their side, spent more time with them, did not feel alone and were understood by nurses. It is emphasized that it is important for individuals with mental disorders to be accepted by the society, to be understood and to establish therapeutic communication.²⁸ It is thought that the most practical and effective way to meet these needs of patients in psychiatry clinics is the nursing activities performed by psychiatric nurses.^29,30 Patients in psychiatry clinics have reported that they need active periods of time in which there is an apprehensive approach that they can share with nurses and whereby they can establish ties with them. The patients have stated in a study that the activities they carried out together with health professionals added meaning to their daily living, improved understanding between the team and the patients, enhanced socialization, improved adaptation to the clinic, and helped the health professionals to better define the moods of patients.³¹ In the study of Moreno-Poyato et al³² the patients have reported that they had limited communication with the nursing team and wished to establish more interaction with the nurses, that the lack of communication restricted therapeutic relationship and a tense insecure therapeutic environment was a factor that prevented establishment of a therapeutic relationship.

The patients stated that they did not want to take part in these activities when they were first hospitalized, but after they took part in the activities, they had a feeling of relaxation, started doing things that they did not want to do before, their stress eased and all these enabled them to engage with life. It can be said that their occupation during the day can reduce anxiety and muscle strain, and increase life energy and positive feelings in individuals with mental diseases. In a study, the patients said the following about the nursing activities carried out in the clinic: “I was an introvert, but I was able to talk to the crowd in meetings”, “I wasn’t able to walk out through the door. When I assumed the duty of shopping, I had my self-confidence again”.³ Çakmak et al¹⁹ have shown in their controlled study that psychosocial therapy approaches such as occupation, hand crafts, painting, sports, and good morning meetings led to significant increases in personal and social performance scores in both the psychosis and non-psychosis patient groups.

The patients stated that they had the opportunity to learn things they did not know owing to the patient trainings and that these trainings were useful and they gained awareness. Individuals with mental disorders need strengthening trainings in subjects such as disease, medicines, period after discharge, and coping skills.²⁸ It can be said that the planned trainings organized by nurses meet the information needs of patients. In a study, patients said the following about the nursing activities conducted in the clinic: “The information I got about sleep in the training meetings helped me sleep more regularly”, “Information on coping with stress reduced my fears”, “I got information about my treatment and medications”, and “I started using my medication on a regular basis”.¹⁴ Nieminen et al³³ reported in their study where they assessed the effectiveness of the training event provided to strengthen individuals receiving mental health services that the training improved social interaction, reduced feeling of loneliness, strengthened positive inner resources, and added meaning to life.

After the activities, the patients had very nice and positive feelings and relaxation, their distress diminished, they felt peaceful, happy and valued, and their self-confidence improved. Individuals with mental disorders need motivating and positive feelings that enhance recovery and participation in the treatment and care. It is necessary for nurses to provide emotional care to meet the patient needs in the areas of mutual trust, emphatic approach, respect, honesty, acquiescent approach, and warmth.³⁴ It can be said that nurses include emotional care in the activities they organize in psychiatry clinics to create a therapeutic effect on patients. Çakmak et al¹⁹ found that using occupational activities in treatment led to a significant improvement in the “Individual and Social Performance Scale” scores of non-psychosis psychiatric patients in particular, compared to the control group. It can be said that nursing activities have a therapeutic effect on patients. The activities nurses carry out with patients are reported to reduce stress in patients and provide them with the support they need.³⁵ In a study conducted in two adult acute psychiatry clinics, the patients have stated that the daily meetings were effective and the group activities were both distracting and enabled interaction with health professionals.³⁶

The patients have reported that all activities were good and nice, carefully planned practices, they had pleasant and delightful time, they were happy with the activities, and some of the films watched during the movie hour were humorous and made them joyful. This suggests that the nurses were able to know their patients in bio-psycho-social-cultural-spiritual terms and they planned and put into practice the activities that satisfied patient requests. Considering that the nursing profession consists of science and art, it can be said that it is important that the roles of nurses are multidimensional. Nurses play a major role in providing psychosocial care to individuals with mental disorders. It has been emphasized in the literature that the quality of nursing care effects patient satisfaction.³⁷ In another study, the satisfaction with psychiatric services has been found significantly correlated with the therapeutic setting of the clinic and the therapeutic relationship established with the primary caregiver.³⁸ In a study investigating the patients’ activities of daily living in a psychiatry clinic, the patients have reported that health professionals should be more active in group interviews, and activity provision and participation and that most of the patients wished that activities such as painting, knitting, music listening, and exercising are implemented, these activities would enrich their daily living, facilitate distraction, reduce their stress and anxiety, and enhance their hope and recovery.³¹

After the activities, all the patients thanked and expressed their wishes for the continuation of all these activities. It can be said that by thanking for the nursing activities and wishing continuation of them, the patients showed that they were happy with them.

Conclusion

Nurses in psychiatric clinics have important roles and responsibilities in creating a therapeutic environment. In our study it was found that nursing activities improve togetherness with other patients, creation of a family atmosphere, and friendship and communication; make patients to feel that health professionals are on their side; promote engagement with life and enable patients to acquire information. Also it was found that nursing activities enhance the patients feelings of relaxation, happiness, confidence and being valuable. Nursing activities organized in psychiatric clinics will contribute positively to patient satisfaction and recovery. In studies to be conducted on this subject our recommendation is to enrich the contents and quality of the nursing activities already being implemented (drama, music, art therapy, etc) and to measure and assess their results. We also think that it can be applied in other psychiatric clinics or cultural contexts within clinical possibilities.