Lived experiences of student nurses caring for intellectually disabled people in a public...

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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 [Unpublished]: University of Johannesburg.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


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


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


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


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.

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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


Guideline 1: Facilitating mental health

of student nurses wholistically: body,

mind and spirit in caring for


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


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

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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

102

APPENDIX I

APPENDIX J

103

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

104

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.

Lived experiences of student nurses caring for intellectually disabled people in a public...

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