Communication Skills of Novice Nurses at Psychiatric Hospital in Saudi Arabia

Objective: The objective of this study is to describe the novice nurses' perceptions of communication skills in Saudi Arabia. Method: A questionnaire developed by Moss that examined nurses’ communication with psychiatric patients was used. The questionnaires were collected during the month of December, 2016. Results: A total of 59 questionnaires were obtained from 89 participants, representing a 66.29% response rate. Findings revealed that novice psychiatric nurses faced challenges in communicating with psychiatric patients. Education and training from either nursing college or hospital orientation program were lacking. Conclusion: Nurses who have been in work for more than 12 months were confident in their communications with psychiatric patients. Nursing and hospital orientation program should be improved and empowered to prepare novice nurses for the psychiatric setting.


Aim
The aim of this study was to evaluate perceptions of novice nursepatient relationship and to describe the extent of communication skills of those novice nurses who were placed to work in a secondary care hospital specialized for mental disorders in Jazan, a southwest region in Saudi Arabia. Knowing such perceptions could help to get both hospital and regional nursing leaderships aware of novice psychiatric nurses' use of communication techniques with psychiatric patients.

Method
The study was based on a survey questionnaire validated and previously been used. The main advantage of the questionnaire is that it is an efficient and effective method of collecting self-reported data from the participants [10]. The primary version of instrument which developed by Georgaki et al. [11] examined nurses' truthful communication with cancer patients. This was modified, validated and used by Moss [12] in psychiatric patient. The modified version was adapted in this study and further demographic questions were added in accordance to Saudi's context. It consists of seven demographic questions and 17 items focused on novice nurses communication with psychiatric patients. The 17 items were in the form of Likert scales ranging from one to five, where one means strongly agree, second means agree, third means disagree, fourth means strongly disagree and fifth means not sure. The last question was an open-ended question that ask participant to note any concerns related communications with psychiatric patients and how to improve it.
An interpretation to Arabic language was made by an accredited translation office. The researchers reviewed the validation of the translation and compare it with original questionnaire and then a very little revision was made. The pilot study was conducted in both languages Arabic and English. The pilot test was focused on how nurses find instructions and questions? Is it understandable and clear or they suggesting any modification? Five nurses who conducted the pilot test suggested a very little clarification in the Arabic form. The clarifications were then made and reviewed by both researchers.
An ethical approval for conducting this study was obtained from ethical committee of Health Care Services in Jazan region. An anonymous self-reporting, questionnaire and participation was made by consenting voluntary participants. Participants were encouraged to read the explanatory statement before deciding to participate in this study. The explanatory statement clarified that returning a completed questionnaire would be considered as implied consent.
Only novice nurses who have a work experience in the psychiatric hospital for less than 24 months were considered for this study. Therefore, a convenience sampling was proposed to recruit participants. This sampling approach is considered appropriate for small exploratory quantitative studies [13]. The questionnaires were collected during the month of December, 2016.
Questionnaires were checked for completeness and legibility. All questionnaire items, except for the open-ended responses, were converted to numeric codes, to enable data entry into Microsoft Excel and SPSS Version 20 for analysis. Data entry was considered an errorprone process [14], therefore one researcher (ZM) enter the data carefully and then 10% was checked at random by the other researcher (MA) to ensure the accuracy of data entry. A unique identifier in the form of an identity (ID) number was assigned to each questionnaire and this identifier was utilized to indicate authentic citations. The use of authentic citations increases the trustworthiness of the data and demonstrates how the themes were developed [15].
For data analysis, descriptive statistics were used to describe and summarize the demographic data, including age, sex and years of nursing experiences. Measures of central tendency and reliability statistics were calculated describe the rest of the survey items. Openended responses were thematically described.

Results
Approximately eighty-nine nurses were identified as novice in the psychiatric hospital; therefore the questionnaire was distributed to all of them. Only 59 returned the questionnaire. This represented 66.3% of the response rate. Four questionnaires were excluded because they were uncompleted. Consequently, 55 questionnaires were considered for the statistical analysis.

Participants demographic
Majority of the novice nurses were Saudi nationality (76.4%) and male (62.8%). The average years of professional experience were 3.05.
The experiences in the psychiatric hospital were 27.3% have less than 12 months experience, 61.8% have 12-18 months and only 10.9%, their experiences ranges from 19 to 24 months. Other demographics data are shown in Table 1 Table 3 shows the effect of experience in mental hospital with regard to the competency of the novice nurses in communicating with aggressive patients. As you can depict from the Table 3 that only 6 out of 15 nurses who work in psychiatric hospital for less than 12 months perceived able to communicate with aggressive psychiatric patients while 34 out of 40 nurses who work more than 12 months were able to communicate so.  Table 3: Cross tabulation between communication with aggressive patient and experiences in psychiatric hospital. Table 4 also shows the effect of experience in mental hospital with regard to feeling of difficulty of communication with patients with mental illness. As you can depict from the Table 4 that 13 out of 15 nurses who work in psychiatric hospital less than 12 months have difficulty communicating with patients with mental illness, where only31 out of 39 who had experience more than 12 months did not have difficulty in their communication.

Psyc Experience Total
Less than 12 months

Comments regarding communication with psychiatric patients
Additional comments related the concerns of communications with psychiatric patients and how to improve emerged the following findings.
One nurse stated that nursing college was prepared student in general nursing and psychiatric nursing knowledge was lacking. Many nurses claimed that more education and training for novice psychiatric nurses were needed. Particularly education of both how to communicate with psychiatric patient based on their diagnosis and psychiatric medications. Another nurse recommended further education for how to communicate appropriately, be patience, provide emotional support and build a good relationship with psychiatric patients.
Further comment indicated that psychological and social awareness should be considered by nurses when approaching communication with anyone. One nurse suggested that dealing with psychiatric patients kindly, meet their needs and do not let them be alone should be considered as well.
One nurse suggested that psychiatric patients might not treat appropriately from their families or friends and this might worsen the patient's conditions. Therefore they need quality of care from a well prepared and qualified psychiatric staff. One comment indicated that psychiatric patients needed more attention from the all staff. One nurse claimed that the availability of social worker and social psychologist 24 h daily were important to meet the patients' needs.
One comment indicated that patients continuously requested nurses that they wanted call their families and limited access of call could trouble both patients and nurses. On the other hand nurses claimed a requirement to establish entertainment activities, exercises and games for psychiatric patients.
One comment stated that scarcity of security could effect on psychiatric patients relationship and trust in the treatment that given by nurses particularly when nurses provided security roles, restrain or seclusion.

Discussion
The findings of this study revealed that nurses who worked more than 12 months in psychiatric setting were confident to communicate with psychiatric patients. Nurses who worked less than 12 months had experienced difficulty communicating with psychiatric patients. Duchscher [8] recommended that focus on communication is the cornerstone of the care for psychiatric patients. Thus it is important to improve the novice nurse's communication skills in the beginning of their working period.
One comment suggested that psychiatric nursing knowledge was lacking in nursing college. This comment may request further education and training should be implanted in the nursing college. Moreover, more education and training for novice psychiatric nurses at the hospital should be enabled to improve their communicate skills and how to deal with psychiatric patients competently.
Another comment stated that nurses provided security roles, restrain and seclusion. This can disturb the relationship between nurses and psychiatric patients. They may not trust nurse's treatment anymore. The scarcity of security could become a big challenge for psychiatric nurses to build a relationship with psychiatric patients.