Experiences by student nurses during clinical placement in psychiatric units in a hospital

Opsomming Abstract ‘n Verkennende studie is onderneem met die doel om moontlike ervaringe wat deur psigiatriese verpleegkunde studente tydens kliniese plasing in ‘n psigiatriese eenheid ondervind mag word, te ontdek en te beskryf. ‘n O ngestruktureerde onderhoud is met elk van die deelnemers tydens hul eerste plasing in ‘n psigiatriese eenheid gevoer om die faktore wat hulle as stresvol beleef het, te identifiseer. Die bev indinge het getoon dat al agt deelnem ers gemiddelde tot hoë stres beleef het. Bronne van stres wat geidentifiseer is sluit, onder andere, die volgende in: oneffektiewe onderrigen leerprogramme, swak bestuur van die d ien s, a fsy d ig h e id van p ro fe ss io n e le v e rp leeg k u n d ig es je e n s hul o n d e rrig ro l, sw ak verhoudings onder personeel, te veel steun op die mediese model van versorging en verwaarlosing van pasiënte. Die psigiatriese verpleegkunde studente wat by die studie betrek is het almal ondersteuning vir die volgende aan g ed u i: in d ie n so p le id in g v ir p ro fe ss io n e le verp leeg k u n d ig es, verandering van houding van pro fessione le verp leegkundiges teenoor studente, o n d e rs teu n in g v ir s tu d en t in is ia tie w e , s tu d en t betrokkenheid in pasiëntsorg en toereikende toewysing van hulpbronne vir pasiëntsorg en verpleegopleiding. Die verkenning en beskrywing van ervaringe wat deur psigiatriese verpleegkunde studente ondervind word sal verpleegopvoeders help om kliniese leergeleenthede op so 'n manier te beplan dat dit minder stresvol sal wees. Dit sal verseker dat studente toegerus sal wees om hulself as terapeutiese instrumente te gebruik. An exploratory study was conducted with the aim of discovering and describing experiences of psychiatric nursing students during clinical placement in a psychi­ atric unit. For the purpose of the study an unstructured interview was conducted with each participant during their first placement in a psychiatric unit to identify the factors experienced as stressful. The results indicated that all eight participants experi­ enced average to high stress. Sources o f stress identi­ fied included, among others, ineffective teaching and learning programmes, poor managerial governance of the service, detachment of professional nurses from their teaching role, poor relationships among staff, over­ reliance on the medical model of care and patient ne­ glect. Psychiatric nursing students sampled indicated univer­ sal support for in-service education and training for professional nurses, attitude change of professional nurses towards students, support for student initiatives, student involvement in patient care and adequate allo­ cation of resources for patient care and nurse training. The exploration and description of experiences of the psychiatric nursing students will help nurse educators plan clinical learning opportunities in such a way that they are less stressful, thus ensuring that psychiatric nursing students are equipped to utilise themselves as therapeutic instruments.

An exploratory study was conducted with the aim of discovering and describing experiences of psychiatric nursing students during clinical placement in a psychi atric unit.
For the purpose of the study an unstructured interview was conducted with each participant during their first placement in a psychiatric unit to identify the factors experienced as stressful.
The results indicated that all eight participants experi enced average to high stress.Sources of stress identi fied included, among others, ineffective teaching and learning programmes, poor managerial governance of the service, detachment of professional nurses from their teaching role, poor relationships among staff, over reliance on the medical model of care and patient ne glect.Psychiatric nursing students sampled indicated univer sal support for in-service education and training for professional nurses, attitude change of professional nurses towards students, support for student initiatives, student involvement in patient care and adequate allo cation of resources for patient care and nurse training.
The exploration and description of experiences of the psychiatric nursing students will help nurse educators plan clinical learning opportunities in such a way that they are less stressful, thus ensuring that psychiatric nursing students are equipped to utilise themselves as therapeutic instruments.

Introduction and problem statem ent
The system of nursing education has laid down extensive preparatory requirements for aspirant nurses in both the theoretical and practical components of their basic nursing education programs (Setsoe, 1992:32).
The acquisition of knowledge and experience in nursing specialities, used for selected learning experiences, allow these students to acquire increasing levels of skill in prac tice, and to emerge as expert nurses ready to provide a service of a comprehensive nature.
Research has identified nursing as a high stress profes sion.Nurses cope daily with extreme physical and psycho logical demands inherent in providing care to acute and chronic populations.These demands of caring for others can be extremely stressful (Wheeler & Riding, 1994:527).
Hlonipho (1994:2) noted that the experiences together with the major responsibility that students face while still un dergoing training, for example learning unfamiliar and com plex theory, as well as the practice of nursing, involving very ill and highly disturbed patients causes severe stress.Clinical experience is a basic component of the professional curriculum and serves as a unifying mechanism wherein concepts are rendered meaningful and principles tested.
Research acknowledging stress experienced specifically by student nurses has been extensively reported.The most common theme apparent throughout the literature on stress in the clinical experience, is that of students worrying about personal inadequacy and the possibility of making errors (Hlonipho, 1994:4;Kleehammer, Hart & Keck, 1990:186).Kleehammer et al. (1990:186) indicated further sources of anxiety to include procedures, inadequate hospital equip ment, and interpersonal relationships with physicians and teaching staff members.They also reported that the high est level of anxiety expressed by students concerned the initial clinical experience.The stressful nature of this expe rience was also reported by Pagana (1988:419).Thyer and Bazeley (1993:337) reported that the presence of stress can have implications for work performance, and could lead to mental ill health and psychomotor disorders.The authors also reported that students who experience unre solved stress and lack of emotional support are likely to experience impaired learning and performance ability, Most of the studies on stress experienced in psychiatric settings focused on registered psychiatric nurses and psy chiatrists (Gray & Diers, 1992;Handy, 1991:44;Jones, Janman, Payne & Rick, 1987:131).These groups of mental health professionals reported experiencing greater inter personal involvement with their patients.This intimate con tact and often intense relationship with disturbed people accounted for high levels of stress.They also reported that working in unresponsive, unappreciative and uncommuni cative environments caused high stress.
Results from the above studies further indicate that psy chiatric nurses are exposed to stressors common to other areas of nursing, for example staffing levels, overwork, ad ministrative duties, to name but a few.In addition they face unique problems in their day to day work that reflect their interaction with a particular client group.
As Sullivan (1993:594) states, having to deal with patients who become physically violent, those that require continu ous observation on a one-to-one basis because of their unpredictable behaviour and nursing a suicidal individual with a lack of manpower necessary to maintain a safe level, are unique problems of a nurse in a psychiatric setting.
It is reasonable to assume that student nurses working in mental health settings are as susceptible to stress as other mental health practitioners.The literature indicates that there is a relationship between stress and learning.While some degree of stress is neces sary to optimise learning, high levels of anxiety can impede learning and inhibit optimal functioning (Tyler & Ellison, 1994:470).
It was found that when threat due to failure interacts with anxiety, interference with discrimination and abstraction is observed.Stress has a detrimental effect on skilled behav iour.This is pertinent in nursing education because dis crimination, abstraction and skilled behaviour are neces sary for safe, effective clinical practice.
Pagana (1988:418) noted that learning to be a nurse is stress ful when she described it as "a perilous enterprise because it requires learning how to cope with many difficult and stressing situations ".It is possible then, that learning within these situations may be compromised due to the anxiety produced.
The stressors experienced by student nurses in the psy chiatric units of the North West Province in South Africa have not been researched.

Purpose and objective
The purpose of the study was to explore and describe ex periences by student nurses during their first clinical place ment in psychiatric units.Nurse educators can then use the knowledge on stressors experienced by student nurses in the psychiatric clinical situation to plan clinical learning opportunities in such a way to make them less stressful, thus enhancing learning and practice skills of nursing stu dents.

Research design
A qualitative study that was contextual, descriptive and exploratory was used with the objective of obtaining in sight into the critical data required on the phenomenon being studied, and collecting accurate information.
The study was conducted in the psychiatric section of a hospital in the North West Province.This section is a 450bed institution serving a catchment area of a population of approximately 750,000.It accommodates both chronic and acute mental patients.It is a teaching hospital for nursing programmes and it is the only institution in the area that offers psychiatric clinical experiences for nurses pursuing the integrated Diploma in Nursing (General, Community, Psychiatric Nursing) and Midwifery.

Purpose and research objective
This study focused on the experiences of student nurses during clinical placements in psychiatric units.The pur pose of the study was to explore and describe experiences of student nurses during their first clinical placement in psychiatric units.Nurse educators can then use the knowl edge on experiences by student nurses in the psychiatric clinical situation to plan clinical learning opportunities in such away to make them less stressful, thus enhancing learning and practice skills of nursing students.

Terminology Psychiatric Nursing Student
A learner acquiring knowledge and skill in the practice of psychiatric nursing during the third year of training.

Psychiatric Unit
A setting in which psychiatric nursing students receive clinical experience with hospitilised mentally ill patients.

Experiences
Events or circumstances experienced by psychiatric nurs ing students in the psychiatric setting as stress producing.

Research design
A qualitative study that was contextual, descriptive and exploratory was used with the objective of obtaining in sight into the critical data required on the phenomenon being studied, and collecting accurate information.
The study was conducted in the psychiatric section of a hospital in the North West Province.This section is a 450bed institution serving a catchment area of a population of approximately 750,000.It accommodates both chronic and acute mental patients.It is a teaching hospital for nursing programmes and it is the only institution in the area that offers psychiatric clinical experiences for nurses pursuing the integrated Diploma in Nursing (General, Community, Psychiatric Nursing) and Midwifery.
The study population comprised of third year full-time psy chiatric nursing students pursuing the integrated Diploma in Nursing (General, Community, Psychiatric Nursing) and Midwifery.Students following an integrated programme are placed in psychiatric wards for the first time in their third year.A purposive convenience sample of nursing stu dents who voluntarily agreed to participate in the study was selected.A sample of eight nursing students was drawn.
The sample size was depended on saturation of data when no more new data was collected.
Nursing students included in the study were: • those in the third year of the program in a nursing college • those in the above level of study, assigned for the first time to provide care to psychiatrically ill pa tients in the psychiatric section of Bophelong Com munity Hospital • both male and female students A pilot study with two participants from the fourth year of study senior to the proposed sample group was conducted to identify possible problems in gathering data.
To identify the information concerning stressors experi enced by the participants in the clinical situation an indepth unstructured interview was conducted.Two ques tions were asked: • Describe the factors which cause you stress while working in a psychiatric unit • What would you recommend to reduce your stress and improve your placement in a psychiatric unit?
Each interview session was tape-recorded and transcribed.
Notes were also taken during data gathering.
For the purpose of the study Guba's model for establishing trustworthiness of qualitative research was used (Krefting 1991: 2 15).The model is based on four aspects: truth value, applicability, consistency and neutrality.Strategies applied to ensure trustworthiness were: Credibility: The researcher is a registered nurse with ten years experience as a tutor.Interviews were conducted on different days and times with different participants.Field notes were taken.An independent co-coder was used.The research was conducted under the supervision of an expe rienced qualitative researcher (with doctoral degree in nurs ing).
Transferability: A purposive convenience sample was used.A complete description of the methodology includ ing literature control and verbatim quotes from individual interviews were included.
Dependability: Question checking with literature was done.
Tesch's steps of data analysis were followed (Creswel 11994: 155).Consensus discussion between researcher and co coder was done.

Results
The data was saturated after eight participants had been interviewed, necessitating no further interviews.
A systematic process of analysing data as described by Tesch and quoted by Creswell (1994:155) was used to en sure uniformity in the analysis of the interviews.Themes, categories and sub-categories were identified from the ex periences described by the participants.An independant co-coder with experience in qualitative research (with doc toral degree) was used.
In analysing the data gathered from the participants, the major themes identified were lack of integrating theory with practice, failure of the service to appreciate a holistic ap proach to psychiatric care, lack of professional support and lack of resources (see Table 1).These themes will be discussed and substantiated by the appropriate quotes from the transcripts and literature.

□ La c k of integration of theory with practice
The findings indicate the existence of two categories in 20  Greaves (1985:40) views integration as a way of organising the curriculum to assist the learner to analyse and apply the relationship between content, concepts and principles in their practice.A nurse must be able to put into practice what she has learnt in theory, apply the knowledge ob tained in classroom situations, exercise educated judge ment and make skilled observations throughout the proc ess of caring for a patient.
To be able to do all this she needs practice skills and infor mation.Skills and information are learnt in an interactive manner.It is impossible to learn one without the other in practice professions such as nursing.

□ Ineffective teaching and learning programme for psychiatric nursing students
Five sub-categories were identified under this category namely, no correlation of theory to practice, no proper ori entation of participants to the clinical situation, unclear/ absence of clinical learning objectives, limited exposure to the clinical units, and overcrowding of students in clinical units.Almost all eight participants described in some way the problem of applying facts learned from a book or in the classroom to the day-to-day nursing care as very distress ing.They reported being unable to understand and corre late what they saw in the wards with what they were taught, and the following excerpt from their interviews characterise this sub-category: "you are in the theoretical setting doing schizophrenia and when you go to the clinical area you are allocated to a mentally retarded ward." The participants of the study used words such as merge, link, apply, to describe this lack of co-ordination.
Half (50%) of the participants reported a feeling of lost and not welcome in the units.The quotation below supports these feelings: "... in fact we did not know what was expected o f us.The orientation we were given did not help us in any w ay... we were lost in those units ... we needed to he supported now and again and this was not forthcoming." Pohl (1978:87) stated that orientation of new workers to the nursing unit is an important process, not only for the effec tive functioning of the unit but also for the personal adjust ment and work satisfaction of the new person.
The present findings are in agreement with Hlonipho (1994:6) who reported that it is a frightening experience for students to be expected to work in the clinical setting before they are orientated irrespective of their level of training.She further stated that 80% of the students experienced high levels of stress when they were not properly orientated, shown pro cedures and given the necessary supportive guidance.
Four of the participants reported that they were unaware of what was expected of them.What were they to accomplish in the patient units in view of the fact that nothing was planned for them?The statements below made by partici pants bear testimony to this: "they do not know why we are in those units ...no objec tives." "when I get into the psychiatric ward, I need to he aware o f what the ward objective are, and at the same time, what the psychiatric ward sister expect o f me ...clear descrip tion o f these will be helpful to us as student, because we will be focused." Available literature emphasises that carefully formulated objectives give both the nurse and the student direction for planning, carrying out and evaluating education (Greaves, 1985:79;Mellish&Brink, 1989:252).
Two of the participants reported being exposed to the psy chiatric unit for very short periods.Two weeks, a month and/or three weeks were cited as placement periods, and this was reported as making learning and caring for pa tients difficult.This is how they substantiated the notion: This finding is supported by Mokoena (1991 :6) who re ported that the preparation of a nursing student into the role of a professional nurse in the work environment was inadequate due to insufficient time allocated for practical work and experience.
Five of the participants reported being allocated in large numbers in one unit and related this to their inability to learn because of insufficient learning opportunities, as ex pressed in the statement below: "About eight or nine students are allocated to a single ward which can actually accommodate four to five stu dents, and as a result the unit is in itself no longer an educative situation, ...We are all there doing nothing, we are actually overcrowded as students." This finding corroborates those of other researches.

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C uratio n is N ovem ber 2 0 0 4 Bestenbier (1992:99), in her study of stress experienced by nursing students during psychiatric clinical practica stated that too many students at various institutions were allo cated to the same wards at the same time.

De-m otivated students
Four sub-categories were identified namely, lack, of inter est in psychiatric nursing, feeling emotionally drained lack of potential or inadequacy in giving care to psychiatric patients and fear of psychiatric patients.
Participants reported being de-motivated and frustrated about being in the psychiatric unit.Newstrom and Davis (1997:37) stated that, frustration is a result of a motivation (drive) being blocked to prevent one from reaching a de sired goal.This situation becomes more serious when there is long-run frustration.
The participants of this study expressed their long-stand ing frustration through concepts such as not interested, bored and discouraged.The experiences of the participants are presented below.
Five participants reported feeling discouraged, having di minished interest and being miserable because of the nega tive attitudes of other staff and the environment they were working in, the statement from their transcripts illustrate this: "The nurses ignore you and you end up hating the situa tion and seeing these nurses as not interested in your wel fare as a student." In a few instances participants quoted incidents in which they were passive observers rather than real participants in the situation.They identified a variety of unit problems that contributed to their low morale, for instance, resist ance of staff especially assistant nurses, to new ideas, feel ings of neglect by the hospital and the college and having no leaders, except for temporary leaders.This led to their withdrawal from both the patients and the staff.
Schwartz and Will as quoted by Gray and Diers (1992:27), defined "mutual withdrawal" (possibly observed in the present study) as a coping mechanism used by nurses to deal with low morale.The withdrawal of nurses from pa tients and from each other occurred in a cycle: nurses expected support from other staff, but did not receive any, and patients expected staff support, but received none.Both responded by withdrawing.
Two participants reported feeling tired, tense and ex hausted" The work stressors that emerged as contributing most to feelings of emotional exhaustion related to the var ied and complex nature and treatment of mental health prob lems as reflected in the statement below: "end up tired the whole day, and at home you are tired." Maslash as cited by Basson and van der Merwe (1992:21) asserts that younger and less experienced workers are more prone to emotional exhaustion than more experienced work ers.The above may be seen by participants as relatively unimportant, but when seen in the light of the developmen tal needs of the student nurses it takes on a different com plexion.Environmental effects such as rigid ward routines and physical feelings of stress such as exhaustion, ac counted for a number of stressors.
Issues of responsibility and fears of giving inadequate care to patients, are a major source of concern among qualified nurses (Parkes, 1985:948).Similar concerns were apparent in the present study.The psychiatric nursing students' vulnerability and inexperience, com bined with the situational demands, were the major factors underlying feel ings of inadequacy in this study.
Almost all eight participants reported feeling inadequate in giving care to patients.The comment below reflects this notion.

"... their behaviour will start to change and you start pulling out o f the situation, you need somebody, you can not handle this by your. "
Two participants identified fear of psychiatric patients as a problem.Experiences were stated in a subtle manner as indicated in the statement below: "Other patients are difficult to manage especially if you are a student.They tend to bully us ... and it will be like you are af raid o f the patient, you cannot do anything fo r the patient ..." The finding corresponds with that of Pagana (1989:402).The comments reflective of uncertainty in her study mainly refer to fear of the unknown and uncertainty regarding ex pectations.Warner (1991:12) reported that students who observed bizarre behaviour in patients expressed their ten sion as surprise, fear, suspicion and embarrassment.The patient behaviours that violated the social norms made stu dents feel tense and uncomfortable.

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Failure of the service to appreciate a holistic approach to psychiatric nursing care Two categories were identified from this major theme, namely: over-reliance of the service on the medical model of care, and failure to provide a therapeutic environment for patients.

Over-reliance of the service on the medical model of care
Over-reliance of the service on the medical model of care was a problem.Proponents of the medical model view emo tional and behavioural disturbances in the same way as they view physical disease.They focus on the diagnosis of a mental illness and subsequent treatment is based on this diagnosis with somatic treatments being the important components of the treatment process.The interpersonal aspect of the medical model varies widely, from intensive insight oriented intervention to brief, superficial medica tion supervision.This view has implications for psychiat ric nursing practice, because when nurses care for psychi atric patients they are primarily responsible for their well being.
Providing nursing care is a collaborative effort, with both the nurse and the patient contributing ideas and energy to the therapeutic process.
Five participants reported that patients were given only medication as a form of treatment and they claim this made it difficult to interact with patients because they remained drowsy for most of the day.
The statement made by the participants bear testimony to this: "you have to use resources in the clinical situation ward fo r the good o f the patient, hut because o f the effects of medication, you cannot use them." Beck, Rawlins and Williams (1988:21), states that the holis tic health principles of practice constitute a framework that can be used in any care setting, and that it enhance quality care.
One of the fundamental roles of the nurse is to enable peo ple with mental health problems to meet their basic needs and to restore the individual's well-being as far as possible, and this she can do by adopting holistic health principles of practice.
Almost all participants reported that recreational facilities were not adequate for patient care.They stated that pa tients were idling for most of their stay, their statements clearly emphasise this aspect.
"what we do is to stay with the patients in the ward, for the whole day, or could actually take them to the sport ground which is no more there, because it is used as an area where contractors are working ... so we just have to stay fo r the whole day Monday to Monday." "you are not only short o f facilities fo r occupying pa tients, they themselves are in tatters." Failure to provide a therapeutic environment Beck etal. (1988:461) refers to a therapeutic environment as the general setting where treatment occurs regardless of the philosophy of treatment.Nursing assumes an impor tant function in the creation of a therapeutic environment in that the nurse provides for healthy interactions and learn ing situations that enable the patient adequate adjustment.Privacy, safety, protection and comfort are components of a therapeutic environment.
According to the participants' statements, patients in this study were not afforded these components.
Of the eight participants, six felt strongly that the use of equipment was not therapeutic for the care of psychiatric patients, they reported that patients were devalued, and this is how they expressed it: "If you can see the dishes they are eating with, the cups they are drinking from ..., are not psychiatrically thera peutic." "eating from dishes that are demeaning ..., not really or human use." One of the participants reported that the physical work environment was not well kept.Wards were described as dirty.Words like filthy and unkept were used.The quota tion below captured this experience: "Psychiatric units themselves are usually very filthy ..., they are not clean ... and because o f the conditions pre vailing there, they are now very dirty and there is nobody who enjoys to stay in such conditions fo r the whole day." The finding coincides with Dawkin, Depp and Selzer (1986:11).The authors identified aspects such as lack of cleanliness and maintenance and noise within the environ ment as distressing.
All the participants reported that the environment was not conducive to patient care" It provided no privacy, protec tion and/or security to patients" The participants' concerns are reflected in their statements: "The environment within the wards is not pleasing, pa tients move around without clothes and there are no fences, so patients' security is not guaranteed.It is like nobody cares."

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Inadequate / insufficient professional support Three categories were identified, namely poor managerial governance of the service, detachment of the professional nurses from their teaching role, poor relationships among staff, management and participants.

Poor managerial governance of the service
Four sub-categories, namely failure of the participating college to place students in an adequate training facility, resisting students inputs into the managerial process, understaffing of registered psychiatric nurses in psychiat ric units and absence of the multidisciplinary team mem bers.
Issues referred to in this category related to organisational practices.Stress centred around practices that indicated valuing of the service over clients and staff, and an uncom municative work environment that makes changes for the sake of changes.
Services of the participating hospital were in such a state that both patient care and nurse training were threatened.Participants were placed for clinical experiences even though conditions were not favourable, as this was the only psy chiatric hospital in the province.Participants do felt cheated and that their learning needs were not taken seriously.
Five of the participants identified this sub-category as stressful and their experiences are captured in the state ment that follows: "I think if you place students where administration is gen erally poor, you are exposing those students to an area that is very critical, which is going to act negatively to their academic development or their mental development as students." The development of a student nurse involves both profes sional development and personal development, and both are facilitated in the learning process.Involvement of stu dents in decision-making is necessary for the functioning of the college.Even though the participants of this study were involved at decision-making level, they felt their in puts were never accepted and this caused stress for them.
Two of the participants felt strongly about this sub-cat egory.A comment is reflected in the statement below: "Because o f the background o f where we come from, there is this tendency..., that we have to be passive consumers of information.We don' t have to make inputs to the authori ties because I think they believe that they cannot have ideas from people who are supposed to he taught." All eight participants reported that there were understaffing of registered psychiatric nurses in psychiatric units and that this led to insufficient and/or inappropriate guidance in these areas.The statements below bear testimony to this view: "The wards are most o f the time without registered nurse, the bulk o f the personnel allocated to these wards are assistant nurses and a few enrolled nurse ... there are no registered psychiatric nurses.This affects our training, ... because when the sister is off-duty or is not there, there is no one who guides us." Six participants reported that the multidisciplinary team approach is not practised in this institution because of lack of team members.The statement from their transcript em phasise this concern: "There is no psychiatrist... and some o f the patients ... according to our own evaluation can go home, but with out the psychiatrist' s assessment... they remain long in the hospital and finally develop institutional neurosis." Detachm ent of the professional nurses from their teaching role When students join the nursing profession, it is assumed that they know nothing or at the most, little about nursing.
They must be guided to a stage where they can assume responsibility for their nursing actions.This socialisation process has traditionally been and is still the function of professional nurses.
Seven participants reported that the professional' nurses could not impart knowledge and showed minimal interest in the whole process of student learning.Some of their inputs are captured in the statement that follows: "When you request their guidance they refer you to the nurse educators." All eight participants reported that both the ward sisters and the clinical tutors had no interest in their work.The excerpts below summarise this aspect: "In most instances even the presence o f a registered nurse does not help yo u ... they are most o f the time visiting other sisters in other wards.If they are in the ward they are at the nurses station and only giving directives." "At times the psychiatric nurse is there, but the attitude o f the psychiatric nurse is not conducive fo r him and fo r the student to interact." In a few comments participants expressed the desire for clinical tutors to be more supportive and to spend more time with them.One participant said: "As students we are expected to be continually assessed but the clinical tutors do not make themselves available in guiding us, you know ... thus it becomes difficult be cause we meet at a specific time, and fo r the rest o f the time you don't integrate with them."

Poor relationships among s ta ff, m anagem ent and participants
Problems reported by the participants included ineffective/ inadequate interaction and communication that not only affected students but was also noticeable between nurse educators and ward sisters, and between ward sisters and management.One sub-category was identified.
Interpersonal problems between juniors and those in charge, are widely regarded as sources of stress in hospital set tings (Parkes, 1985:947).In the present study many of the interpersonal problems reported were due to attitude prob lems.Experiences below capture this: "The nurses on the other hand are not friendly, their inter personal relationship is not good and this obstructs you as a student from asking questions." "Being treated like ordinary workers " was also a frequent and understandable source of resentment, since the major ity of these participants were striving to achieve a profes sional status and independence.
Working relationships between staff members were also a potential source of problems.Participants expressed con cern at the attitude of the ward sisters to nurse educators, and this they said occurred sufficiently frequent to have a lasting and adverse effect on their motivation, as captured in the following experience of a participant: the students may not e ... are not that much interested and even the psychiatric nurses working in there, does not interrelate rightly to the tutors, to the extent that they can hardly transfer what the tutor told them to transfer to us, as it is ..." Parkes (1985:947) made a similar finding.He pointed out that the tendency for ward sisters to reprimand students who had made mistakes, rather than to respond to their needs and the distress this caused for students.The sub jects in the perceived themselves as powerless to argue even if they were blamed unjustly.

□ La ck of resources
The findings indicated one category in this major theme, namely, patient neglect.

Patient neglect
Students were concerned about non-professional nurses taking charge in psychiatric units and patients being mis used.
Almost all participants reported concern at the free use of both assistant nurses and enrolled nurses as charge nurses in the psychiatric units.Their statements bear testimony to this: "A psychiatric ward is run by enrolled nurse ... she is just using her experience, but she is actually not qualified ..., she uses more o f the practical part o f it, which is not ac cording to theory." "... these nurses at times give patient over-dosage because they do not know anything about psychiatric care." Participants of the present study felt they were not gaining anything from the psychiatric hospital because they were supervised and taught by this enrolled category.
Four participants reported that patients were abused by using them to do duties for which personnel were hired.Patients were cleaning other patients, feeding those who were unable to feed themselves and cleaned the units.The participants reported this as follows: "Patients are used as workforce to dean the wards even though cleaners are hired and are paid." One participant stated that it was demoralising to observe the treatment offered to patients.He had this to say: "Patients are really not cared for.As a student you always ask yourself how you will feel if it was brother or father being treated this way the way they are treated increases the stigma attached to them."

Conclusion
The present study aimed at identifying factors that cause stress in psychiatric nursing students.
The main theme that evolved from the content analysis was that participants' stress was increased by what they experienced as non-supportive staff in the clinical situa tion.This finding is supported by those of Pagana (1985:422) and Kleehammer et al. (1990:187).The concurrence of find ings is an indication that clinical staff needs to be continu ally cognisant of how their interactions with students are perceived.Clinical nursing personnel seen to be non-sup portive may have a great negative impact on the student's ability to learn due to stress.
The non-stimulating, non-supportive environment in which the participants found themselves, affected them so seri ously that they were not interested and had no potential for giving patient care.
Relevant knowledge and skills are largely inevitable in the early stages of training, but the initial placement in the clini cal situation, (as in the case of these students) can be excit ing and challenging if careful teaching and supervision are provided.
Ward sisters and senior nurses are charged with this func tion.But one must not lose sight of the fact that ward sis ters themselves are under considerable stress and they see patient care, rather than teaching students as their first priority.This was also indicated in the responses of partici pants, who stated that they were referred to the tutors when they requested assistance from sisters.A further reason for their reluctance to teach may be the lack of the skills neces sary to carry out these two conflicting aspects of their role.
A generally negative conception of management was noted in the study and this deserves some explanation.The find ing suggests that the psychological conditions in which psychiatric nursing students work may be problematic.The students in the current study held strong views about the organisational characteristics of the research setting and believe that their views were not taken into consideration when important decisions were taken.
The results could indicate the reality of the situation or alternatively, they could reflect some underlying feeling of discontent manifesting in this manner.As Trygstad (1986:25) noted, discontent amongst nurses is a comment on the style of leadership, patterns of communication and quality of interactions that operate within the work environment.
Ultimately an individual's experience of stress occurs within an organisational context and the contextual variables in operation will affect the appraisal of stress by the indi vidual.
The psychiatric clinical setting of this study was part of a particular set of organizational relationships.Being part of the National Health Service facilities, all interactions took place within a specific social climate which was character ised by uncertainty.
The economic situation and changes in the political phi losophy have produced a culture characterised by reduced financial provision for health care accompanied by an in creasing demand for these services.The organisation of care within these services is therefore a reflection of a par ticular structure, and various policies and procedures in operation impose various constraints.While some sources of stress are the result of the clinical work of nurses, others reflect a specific organisational context.

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The hours allocated fo r psychiatric nursing practise are very short, sometimes you are allocated fo r two weeks and you cannot do what you wanted to do.... like you want to implement a rehabilitation programme fo r the patient.It means you work only the first week to establish a working relationship you cannot do all that you wanted to do fo r the patient.'' "This is our second exposure to the psychiatric clinical units ... I can say this is the third week because last time it was only two weeks and I really gained nothing. "

Table 1 :
M ajor them es, categories and sub-categories • Use of patients as workforce this major theme, namely, ineffective teaching and learning programmes for psychiatric nursing students and de-motivated nursing students.