الفهرس 
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Abstract
Psychiatric-mental health nurses are expected to integrate the principles of psychotherapy within their practice in order to provide an effective bio-psychosocial integrative care to their patients. The present study attempted to assess psychiatric-mental health nurses’ therapeutic role in psychological therapies. A mixed methods explanatory design which includes both quantitative and qualitative approaches was used in the study. A sample of 180 psychiatric-mental health nurses was selected randomly in the first phase while a purposive sample of eight nurses was used in the second qualitative phase. Methods of data collection were (therapeutic role of the mental health nurse)’s questionnaire and ”psychological therapies within the context of psychiatric nursing practice” tool.
The conclusions of the study were drawn from the findings of both quantitative and qualitative studies. This chapter explains the study conclusion and recommendations. It begins with a summary of the major findings in response to the research question ”Do psychiatric-Mental Health Nurses have a therapeutic role in psychological therapies?”, followed by a mixed analysis and declaration of the study limitations, respectively. Finally, recommendations are offered, including recommendations for improving mental health services, nursing education, and future research.
Summary of the findings
Summary of quantitative study findings
The findings of the quantitative study identified that age range of the study sample was (20-59) years. Thirty seven point two percent (37.2 %) of the sample ranged in age category 20 to less than 40 years. Sixty-six point seven (66.7 %) of the sample were females while 33.3% of them were males. Regarding to educational qualifications of the subjects, Seventy-three point nine percent (73.9 %) of the sample hold a diploma degree in nursing while 8.3% hold a bachelor degree. Concerning setting of work, 96.1% of the respondents were working in inpatient units vs. 3.9% were working in rehabilitation units.
In relation to therapeutic strategies used by PMHNs, The strategies with the strongest level of agreement were ”maintaining safety and aggression minimization”, ”intervening early when becoming ill”, responding promptly to medication issues”, and ”mental status assessment and physical health assessment”. The strategies attracting the most disagreement were” sharing activities with patients”, where 34.4% of the study sample were disagreed or strongly disagreed that MHNs ”support families and friends of the patient”. Regarding ”maintaining regular contacts with the patients”, 76.1% of respondents disagreed or strongly disagreed that MHNs employed this strategy.
Considering non-pharmacological approaches used by PMHNs, ”no intervention-observe only”, ”practical problem-solving techniques”, and ”changing negative thoughts” were the most popular strategies employed by Psychiatric-Mental Health Nurses. The least popular approaches were ”offering relevant Internet-based self- help informations”, ”daily notes of feelings”, ”developing a recovery plan”, and ”providing written in formations about the disease”.
Concerning psychological therapies used by PMHNs, Psychological therapies or techniques that received the highest response rates were ”counseling” by percentage of 38.9%, ”group psychotherapy” by percentage of 8.3%, and ”solution focused therapy” with the same percentage of 8.3%. While the therapies/ techniques with the lowest response rates were ”mixture of previous methods”, ”psychoanalysis”, and ”Cognitive Behavioral Therapy” by percentage of 2.2%, 2.8%, and 3.3% respectively.
Regarding the relationship between using psychological therapies in practice and socio-demographic characteristics of respondents, there were no significant statistical differences found between nurses in terms of age, gender, experience, and current place of employment. However, educational qualifications, setting of work, and daily caseload showed some significant statistical differences.
As regards attitudes to CBT, answers of the questions indicated that ninety point six percent (90.6 %) of the subjects showed negative attitudes toward CBT compared with 9.4% who revealed positive attitudes. 88.9% of the study sample ”don’t know what CBT is”. While the remaining part of the sample (11.1%) either agreed or strongly agreed that ”CBT is a valuable treatment”, ”training in CBT should be available to the all” by percentages of 95% and 90% respectively. All of these respondents also agreed or strongly agreed that ”more resources should be available for CBT” and that ”mental health nurses should advice patients about CBT”. In contrast, negative attitudes to CBT reflected by percentages of 15% and 20% that concerning responses of the subjects who agreed or strongly agreed that ”CBT” hinders time” and ”CBT used in minor problems only”.
Concerning the relationship between attitudes to CBT and socio-demographic characteristics of respondents, Chi-square test revealed that there were no statistical differences among respondents in terms of age and gender. However, the same test revealed some significant statistical differences in terms of educational qualifications, experience, place of employment, setting of work, daily case load, and work satisfaction.
Regarding factors limiting the therapeutic ability of PMHNs, the factors received the highest level of agreement and strongly agreement are ”too many forms to fill out”, ”funding shortage”, ”high patients to staff ratio”, and ”nurses spend too much time doing observations”. In relation to factors influencing the use of psychological therapies by PMHNs, ”lack of training” and ”lack of resources” were the answer options that respondents most agreed or strongly agreed with. Whereas,” I don’t believe in psychological therapies” was the answer option most disagreed or strongly disagreed with.
Summary of qualitative study findings
The findings of the quantitative study identified four themes in relation to practices of psychiatric-mental health nurses which are: (1) traditional nursing role, (2) therapeutic nursing role (3) skill acquisition, and (4) suggestions for improving the profession.
The first major theme that emerged from data analysis was related to the ”traditional role” of psychiatric mental health nurses and included two sub-themes. The first sub-theme was related to custodial interventions as hygienic care, medication administration, observation, physical and behavioral assessment, and patient’s safety. The second sub-theme was related to the administrative functions as documentation, admitting patients, and contacting the psychiatrist.
The second major theme that identified from analysis nurses’ comments was related to the ”therapeutic role” of psychiatric mental health nurses which include six sub-themes. The first sub-theme was related to therapeutic factors used by psychiatric mental health nurses while caring for their patients as maintaining trust relationship, maintaining psychological safety, providing emotional support, installation of hope, preparing for a therapeutic millieu, and nurses’ personal qualities. The second sub-theme emerged was prevention of illness relapse as nurses reported using some of these strategies in their practice as encouraging adherence to medications and social skill training. The third sub-theme identified from data analysis was concerned with cognitive interventions which nurses use while caring for their patients in the daily work. These cognitive interventions represented in changing patients’ negative thoughts and challenging the delusional ones. The fourth sub-theme emerged in relation to the therapeutic role of nurses was the ”behavioral interventions” that the nurse used to modify the patients’ negative behaviors or reinforce them to acquire new accepted ones.
The fifth sub-theme concluded from the data and emerged within the therapeutic role of nurses was the” spiritual interventions” as the nurses reported that they use some of the religious instructions and practices with their patients to promote their emotional state or change some of the negative thoughts. The final sub-theme identified from nurses’ discussions was the ”psychoanalytic interventions” as nurses were assuming the role of surrogate that resembles the strategy of transference and counter transference used in psychoanalytic therapy. This sub-theme has been inferred indirectly through nurses’ words.
The third major theme that emerged in this study related to how nurses acquire their skills in managing psychiatric patients. Nurses reported experience with patients, education, training, observation of others’ skills, effective supervision and inter-professional learning as the methods that help them to acquire and develop their skills.
The forth major theme identified from thematic data analysis was related to nurses’ suggestions to improve their knowledge and skills while caring for psychiatric patients and consequently improving the profession. Nurses’ suggestions were related to fair providing of training courses that are relevant to nurses’ needs. In addition, nurses’ suggestions were related to some administrative issues as morale and financial support.
Did the Findings of the Qualitative Study Corroborate those of the Quantitative Study?
According to the findings of the quantitative study, it was interpreted that psychiatric-mental health nurses had poor knowledge, negative attitudes and little practices regarding psychological therapies, in particular, CBT. There was a superficial contradiction between the findings of the quantitative and qualitative studies as in the qualitative study the ”therapeutic nursing role” was identified as a major theme which summarizes nurses’ usage of some basic therapeutic cognitive, behavioral, spiritual and psychoanalytic strategies. Consequently, it was identified that nurses used basic cognitive behavioral interventions in the daily routine work.
This contradiction between results of the two consequent studies may be related to the actual lack of nurses’ theoretical knowledge regarding the meaning of the concept of psychological therapies, its strategies, and how these vague terms and concepts can be applied. On the other hand they acquire some basic skills resulted from their interactions with patients. When nurses challenged by many situations in which they feel handicapped and not qualified to manage, they seek help from others in the mental health team as nursing supervisors, staff nurses, psychiatrists, psychologists and social workers. Nurses seek help either directly by asking how to deal? Or indirectly by observing team’s members while they managing these situations then imitate them.
Nurses do what is known as experiential learning which may help them to learn how to acquire some skills and practices without informing them about the knowledge or theoretical basis of these interventions. Consequently, nurses perform these basic strategies without being able to determine the title or the type of them or even without being able to determine the intended therapeutic outcomes from its using. This perspective was supported by nurses themselves when they identified observing others and multi-disciplinary team interaction as the main methods which help them to acquire and develop their skills.
It is can be said that the basic cognitive, behavioral, spiritual and psycho-analytic interventions used by PMHNs as identified from thematic analysis of the qualitative study were implementing by nurses automatically as a result of imitating others without being aware of the scientific base and therapeutic effectiveness of these strategies.
Mixed Analysis
As explained in Chapter 3, the present study employed a mixed-methods approach to provide breadth and depth of knowledge about mental health nurses’ understanding and practices regarding psychological therapies. While the qualitative study showed the level of nurses’ understanding, attitudes and practices regarding psychological therapies the qualitative study showed how PMHNs implement their roles and how they integrate psychological therapies within the context of their routine practice. The combination of quantitative and qualitative findings provided more comprehensive understanding about nursing practices regarding psychological therapies than the use of either qualitative or quantitative findings alone (Driscoll et al., 2007, Johnson & Onwueghuzie 2004).
The quantitative study indicated that mental health nurses had poor understanding, negative attitudes and little practices regarding psychological therapies. These findings primarily reflect that a medical model was more prominent. To test these findings further a qualitative study was employed to examine how nurses implement their roles in routine practice and consequently in relation to psychological therapies. The findings of a qualitative study helped to elaborate the qualitative tool. Both descriptive qualitative and quantitative cross sectional studies were employed for the purposes of complementarity, development, and expansion (Greene, 1997).
The findings of the quantitative study revealed that PMHNs had little understanding of and negative attitudes regarding psychological therapies. These results were inconsistent with qualitative findings indicating that PMHNs used basic therapeutic cognitive, behavioral, spiritual and psycho-analytic strategies. Such findings are likely to be explained by nursing education which is traditionally based on a medical model. This matter resulted in lack of nurses’ knowledge regarding modern models of psychiatric care. Findings related to nurses’ usage of psychotherapeutic strategies may be related to experiential learning and observing of other professionals in mental health team.
Although PMHNs reported using of some basic psychotherapeutic strategies as a result of experiential learning, they expected to remain with the same level of knowledge and practice as the nursing education is dominated by the medical model which prevents acquiring or developing new knowledge or skills.
Figure 2 provides a graphic representation of research methods and the findings that highlighted the dominance of a medical model on mental health nurses’ perceptions and practices. It seems to be difficult for nurses to shift their paradigm to modern models of care. In ajar covered by a medical model, medical-oriented mental health nursing was conserved amongst mental health nurses. This is represented as a glass jar in which medical orientated mental health nursing is represented as the lid or the seal which limits new knowledge of psychotherapeutic nursing practice in and therefore limits change.