988368

Introduction
Psychiatric illnesses are one of the biggest healthcare concerns due to their high prevalence and significant disease burden [1]. A World Health Organization (WHO) research estimates that 450 million individuals worldwide experience mental problems, mainly serious depression [2, 3]. According to WHO, in each stage of life, 25% of people experience one or more psychological diseases [4]. Mental and behavioral disorders were the second-highest-rated illnesses in terms of disease burden, accounting for 16% of the overall disease burden in 2003 [5].   
Caring for adults with disabilities is a stressful profession, these people have to work hard and meet strict restrictions; they are not permitted to spend more time alone. Some responsibilities, such as changing diapers for patients who have poor sphincter and urinary control, monitoring the physical health of mental patients and informing the relevant staff, supervising and caring for the patient’s sleep and wakefulness, changing the patients’ clothes and sheets and creating a setting that feels like home, and developing maternal relationships with mental patients, result in the nurses being confronted with difficult situations [6]. 
Some careers and life events are inherently problematic for people, which poses a risk to their mental health. A positive psychologist recently focused on a person’s physical and psychological characteristics to ensure that they can withstand challenging situations and not suffer damage. In addition to developing their personality, people do this when faced with challenging or critical situations. Stress affects medical professionals because they are responsible for treating and comforting patients. The nursing profession is faced with conflict and also because of the emotional demands that are expected from these people and they are likely to experience intense emotional states, so nursing is a challenging profession, especially with regard to the care of these patients [7].
Due to a variety of comorbid medical diseases, concomitant cognitive impairments, resistance to getting treatment, and the prejudices of healthcare professionals, patients with mental problems are at a greater risk of dying [8]. Additionally, these patients require high-quality healthcare services since they use several drugs, are susceptible to their adverse effects, live unhealthy lives, are overweight or obese, and smoke [9]. In turn, the provision of high-quality healthcare depends on the availability of qualified and devoted healthcare workers, particularly nurses [10].
The majority of healthcare professionals at mental facilities are nurses [11]. Offering patients specialized care that will hasten their recovery and facilitate their return to normal lives is the main goal of physical and mental care delivery at these facilities. As a result, high-quality nursing care services can aid patients in mental institutions in returning to regular life more quickly and avoiding readmission [12]. However, there are not enough nurses to provide psychiatric treatment. According to WHO, there were 7.7 nurses and fewer than one psychiatrist per 100,000 patients in psychiatric settings in 2014, indicating a chronic shortage of mental health workers [13].
One of the main causes of the nursing staff shortage in psychiatric settings is nurses’ dissatisfaction (DSS) with their jobs. According to a survey, most nurses only pick the psychiatric wards as their only option because they have no choice [14]. Their negative opinions of such occupations [15], stress, and emotional weariness are factors in their lack of care in working in psychiatric settings [16]. In psychiatric settings, more than half of the nurses are said to experience significant stress and emotional exhaustion [17]. In addition, research found that nursing beginners are unwilling to work in mental facilities because of mental anguish, a range of work-related stresses, and adverse public impressions of such environments. Stressful work environments and a lack of professional nursing processes in psychiatric settings are further contributors to nurses’ DSS [18, 19].
A review of research in this area revealed that some simply looked at nurses’ attitudes toward patients with mental illnesses [20] or identified the causes and consequences of caregiver tiredness and burnout for mental health nurses [21]. Some [22, 23] also looked at the variables affecting students’ interests. Given that qualitative research is context-based and that various outcomes are seen in various domains, prior research has not directly delved into nurses’ perceptions of the reasons behind their DSS while working in mental units. The topic of the proposed study was developed in response to these factors, and the significant effects that this DSS has on the quality and quantity of psychiatric nursing treatment [16, 24] have led to the creation of the current research question. This qualitative study was done to learn more about how nurses experienced their DSS while working in mental hospitals.
Studies carried out outside of Iraq revealed that many aspects of working in psychiatric wards can be stressful; this work environment is often seen differently, less attractive, and therefore less seen by other nurses, as a way to experience physical or mental problems related to work stress, and a way to feel negative in a world that feels like a prison [25-27]. 
In this study, the researchers hypothesized that nurses are unhappy for several reasons, including the fact that the first researcher is a nurse who worked in this hospital and witnessed the nurses trying to move to other departments and the lack of innovation, interest, and motivation in these wards. Also, as a result of the dissatisfaction of nurses in neighboring countries and other Iraqi countries from working in the wards due to the lack of real information about the cause of dissatisfaction in Iraq, the researchers decided to conduct this study to find the cause of this dissatisfaction [14, 19, 16, 5, 28-32].
Psychiatric nurses (PNs) are responsible for providing healthcare to the mentally ill. Dissatisfaction occurs in the workplace where providing services to unaware and mentally deranged clients leads to recognizable limitations and backlashes. Therefore, the current study explored the experiences of those who work continuously with such patients and environments as nurses in the settings of specialized mental hospitals.

Materials and Methods
This qualitative study was carried out utilizing a content analysis in 2021-2022. Exploring experiences in the natural setting is possible through qualitative research. Wildemuth [33] asserts that content analysis is a research technique for drawing verifiable conclusions about the relationship between data and context [33] to generate new knowledge and more insights, present the facts, and offer a useful road map for action. The approach that is used depends on the study’s objectives [34]. This study was done to learn more about how nurses who worked in psychiatric wards saw the factors that contributed to their dissatisfaction. The inductive content analysis technique is advised [35] when a subject is not sufficiently understood or when newly found information is not adequately assimilated. In order to achieve the purpose of the study and due to the lack of information about the experiences of nurses in the above cases, an open phenomenological approach was used in dealing with the causes of dissatisfaction in mental health institutions. 

Setting and sample
This study was conducted on 24 nurses at a mental health ward of Al-Rashad Hospital in Baghdad that serves as a representative of medical facilities throughout Iraq, which is unique at the national level. The requirement for inclusion was the capacity for verbal interaction and employment in a mental unit. Nurses who worked in hospitals and had diploma, undergraduate, and post-graduate degrees while completing academic coursework and mental health training in colleges and hospitals made up the research samples. PNs interested in participating contacted the principal investigator (PI). Those who met the inclusion criteria were then reviewed to see what district they worked in, and what age group they served. To provide diversity in the demographic characteristics of the geographic age group in which the employed nurse was selected for interview. The sampling goal was to select nurses who served at this hospital from different specialties and demographic variations in Iraq. 
Representativeness in qualitative research is achieved through saturation. Without acknowledging saturation, the transferability and applicability to populations beyond the study sample are limited [36]. With regard to the level of education, job experience, and affiliation of eligible participants, sampling was carried out with the greatest amount of variation in order to achieve the greatest amount of diversity in the sample. Variables were chosen according to the opinion of the authors and some qualitative experts. 

Data collection
Individual, in-depth, unstructured interviews were used to collect the data. The interviews continued until no new information, topics, or motifs were revealed by the participants, the interviews began with typical inquiries, such as: Could you kindly explain why nursing in this unit is appealing to you? Based on the participants’ replies and the study objectives, clarifying questions were then employed. These inquiries included the following examples: What prevented you from becoming interested? What took place next? Could you please elaborate? Is this your idea, exactly? The first author outlined the objectives of the research ad before the interviews. According to participants’ demands, interviews were held at their workplaces.
Data collection continued until the formation of categories and data saturation. On average, 42 minutes were spent on each category of the interviews. At the participants’ request, all interviews were taped through a smartphone in a private space at work.

Data analysis 
The authors several times, listened to each session and typed up the transcription in order to become certain of the facts [37, 38]. The interviews were captured using a smartphone audio recorder, and the PI typed the transcription into a Word document. Then, Microsoft Word, version 16 [39] was used to process the transcripts for theme analysis. The development of themes, categories, and codes was done through iterative analysis of interviews. From each interview, key phrases and points related to the study topics were underlined and modified. The specialists and researchers reviewed the approach after 312 important comments were retrieved. Each key remark was given a meaning, which was then grouped into themes. Eight subthemes were found to be present in all reports of employment in the mental hospital, and three theme clusters were found to reflect the experience of research participants. The descriptions of the experiences were given using the themes. Theme clusters and formed meanings were included in the description to build its overall structure and make sure that it encompassed all of the components of the experience in order to explain the phenomena in more detail. 
The lengthy explanation was condensed to the phenomenon’s basic framework. The researchers made an effort to describe the procedure and significance discovered during the earlier stages of the study. The detailed description was sent back to the specific nurses for verification of its accuracy. All of the interviewers said they could relate to this description from their own experiences working in mental units. Table 1 presents an illustration of data analysis.



Trustworthiness
Trustworthiness was assessed using the qualitative research guidelines’ criteria for dependability, confirmability, credibility, and transferability. One researcher held ongoing conversations with study subjects over a six-month period to verify trustworthiness. In a preliminary, two nurses in the pilot study examined the key codes, and the researchers modified them to ensure that the data and experience were converging. The researchers made an effort to be sufficiently responsive to the participants with sustained participation.
The PI reviewed categories and codes leading to sessions to ensure data could be verified. Without personal bias, the researcher created questions depending on the participants’ previous answers, the researcher collected all the audio recordings and after conducting the interviews, transcribed them and also extracted the codes from the data.
Techniques for coding concepts and subjects, as well as textual and audio data, were available to assure the validity of the study results. Also, the resulting codes and categories were evaluated and discussed by two of the writers. Transferability was further improved by sampling a wide range of participant characteristics, including gender, educational attainment, and affiliated ward. Additionally, there were attempts to completely and impartially choose the research samples in accordance with the study goals.

Results
Twenty-four nurses from Al-Rashad Hospital in Iraq took part in the study. The majority of participants (14 participants) were women who worked in the chronic and acute care wards and had a diploma or bachelor’s degree (19 participants). Table 2 lists all of the participant’s demographic information. 


Insufficient training for providing psychiatric treatment, a negative reputation for PNs in the public, and concerns of nurses were the three issues that participants’ views on the evolution of their dissatisfaction when performing nursing in psychiatric wards were analyzed (Table 3).



Insufficient training for providing psychiatric treatment
Participants acknowledged that when they began working in psychiatric wards, they were not prepared to provide psychiatric treatment and had only selected this job because they had no other choices. They believed that working in mental wards was more difficult than working in other hospital wards because of issues, like minimal patient recovery, restricted preparation for work, a lack of enjoyment in the job, inadequate working conditions, and a lack of the expertise required to operate in mental facilities.

Working in mental health wards (forced option)
The majority of interviewees stated that they were forced to work in mental hospitals because of their own medical issues, the intense workload in other wards, or a scarcity of nursing personnel there. Some of them also mentioned the benefits of working in mental facilities, including shorter workdays, administrative visits that rarely enter this department because of the patients’ conditions, no night-time shifting, and more vacation time.
I came to this place of my own free will because of the deterioration of my health in the oncology hospital, I got tired because of the hard work and I have anemia, while the patients here are almost stable and they themselves are repeated, and I’m always adaptive on them and the fact of working here is comfortable (P. 4; a male nurse with an eight-year of work practice)

Improper workplace conditions
Participants reported that they were less satisfied working in mental health facilities due to the repetitive nature of their duties, which made patients unhelpful in treatment, rehospitalization of clients, their limited ability to perform mental healthcare and job pressure. Participants described performance challenges in psychiatric facilities due to slow recovery, lack of significant progress over time, and a distressing perception of follow-up care.
Patients in mental hospitals at no time recover: This situation lacks the positive nursing care sensation, the sense so as to the mental patient is doing better and has obtained a feeling of recovery. (P.11; a female with eleven years of clinical practice in nursing).
If one of my relatives wants to transfer here, I do not advise him to transfer because this hospital is a second world that differs from other hospitals, where he or she does not learn (P.14; a female nurse with thirteen years of work experience).

Not having the knowledge required to attend and work in psychiatric wards
Participants said that compared to nurses in other healthcare settings, mental health nurses have lesser levels of professional expertise. A wide theory-practice gap was also noted in psychiatric hospitals, and these units were described as having repetitive patients and a limited variety of diagnoses. As a result, they observed that they were lazy, had no enthusiasm for their work, and were lagging behind their peers in other departments in terms of professional ability.
In public hospitals, you get to know different diseases, learn from experience, and learn how to intervene with patients in terms of veins, sutures, surgical medicine specialties, and children, while here in this hospital there are specific patients and their work is only hotel services such as eating, changing clothes, and others of services in most cases. When I was in the army, in health institutions, and in other hospitals, I learned a lot of important nursing interventions, but here, unfortunately, I stopped and forgot about it (P. 10; a male nurse with a twenty-year work practice).

A negative reputation for psychiatric nurses in the public
The unfavorable public impression of mental health nurses was a significant barrier to happiness in the field of working in psychiatric institutions. Participants said that misconceptions and negative stereotypes regarding working in psychiatric institutions exist, especially among family members and close friends. Thus, despite spending many years in mental sitting, PNs feel compelled to keep the duration of their employment a secret from others. They cited their own prior experiences while attending university as reasons for their dissatisfaction with working in mental hospitals, as well as the negative opinions of family members and coworkers against psychiatric nursing.

A lack of respect among coworkers for PNs
Participants claimed that other hospital staff in other wards had unfavorable opinions about PNs, had requested them to switch jobs, and had advised them not to select psychiatric settings as their primary profession. These issues have diminished their desire to work in mental facilities.
I was in another general hospital before. A nurse asked me, “what brought you here?” Are you punished and came here? He also asked me if I could change my workplace on my first day at work. He really let me down (p. 12; a female participant with six years of professional practice).

The negative family reputation of PNs
Participants reported that their relatives had unfavorable sentiments toward PNs and had incomplete knowledge of psychiatric facilities and patients. As a result, our participants tried to keep their work a secret. Their mood had been negatively impacted by their family members’ unfavorable views, which also prompted them to become preoccupied with their work and decreased their interest in it. They said their partners thought that mental institutions functioned more as places to house patients than medical facilities, and people were often confined there. Some male nurses also suffered from a refusal to marry him, and the engagement was canceled more than once because of their reputation for working in this hospital.
I was not interested in working in the psychiatric nursing department. I feel constrained by my words, and I am always careful when I explain my duties and the nature of my work to others. I sometimes twist my words and don’t say anything in this matter unless it’s absolutely necessary. I also suffered from a delay in marriage, and the engagement was canceled more than once because of my work in this hospital. They do not understand, and they only say that I work in a crazy house. And thus, it reflects on my actions and personality (a male nurse with nine years of work experience; p. 9).

Past experiences of mental health nurses when studying psychiatry
The study sample stated that they were uninterested in working in mental wards because they had been exposed to undesirable events and attitudes toward mental health nurses (MHNs) throughout their studentship era. Others said they had been violated by patients when they were interns at mental units.
When I spent time in these wards during my practical study, I wasn’t particularly comfortable with it. At the time, I vowed to myself that I would never choose to work in a mental health facility (P. 2; a female nurse with three years of work experience).

Concerns of nurses
This category has two subcategories: Concerns about patient attacks and a concern arising from a lack of knowledge and clients’ issues. The participants’ dissatisfaction with working in mental wards was also attributed to their concerns about patient abuse and their lack of acquaintance with patients. They stated that when they first started working in psychiatric wards, they felt anxious about working in psychiatric wards because of the negative opinions of their friends, coworkers, and numerous others toward patients with psychiatric disorders. Those who were afraid even before they encountered the phrase “patients with mental disorders, attempted not to get connected to them and were frightened when they heard “patients with mental illnesses.

Concerns about patient attacks
Participants were worried about the patient’s attack because they thought that people with mental illnesses may get agitated and violent. Because of their hallucinations and delusions, people with paranoid, schizophrenia patients, and strong-body patients were the main threats to the nursing staff. Such concerns were a key factor for their dissatisfaction with work in mental facilities.
One day, my back was bit by one of the patients, also another time took a blow to my head and lost consciousness. As a result, I am extremely cautious around patients, even in the hospital’s courtyards and gardens; thus, I did not like working here because of my concern about upsetting the patient. Mentally ill patients may suddenly get agitated and hostile and assault you. I was worried that patients might retaliate (p. 5; a female nurse with nineteen years of work experience).

A concern arising from a lack of knowledge and clients’ issues
Because they were not familiar with the patients with mental problems and their characteristics and reactions, the participants reported that they had no interest in this occupation in mental departments. They became anxious when they saw disorders, such as panic attacks or assaults because they were not aware of these individuals and their symptoms. They saw that they had significant levels of stress because they had not learned to deal with the strange circumstances.
I was afraid of these patients at first because I did not know anything about them or their problems, and sometimes it is difficult because the admitted patients have dual diseases, especially women and their suffering is sophisticated. So I decided against staying in this department (p. 13; a female for five years of nursing practice).

Discussion
The findings of this study benefit the managers and employees in general, especially nurses who are in direct contact with mental patients in these institutions, as professional satisfaction reflects the feelings that researchers searched for reasons for turnover or transfer to another place outside these departments.
One of the main causes of the lack of nursing personnel in these settings is nurses’ dissatisfaction with their jobs in psychiatric facilities. Therefore, the purpose of the current study was to explore the experiences of nurses regarding the factors increasing their DSS while working in mental departments. According to the data, nurses’ perceptions of the reasons for dissatisfaction in working in psychiatric wards include a lack of professional skills for providing psychiatric care, unfavorable public perceptions of nursing professionals, and dread of clients.
Insufficient training for providing psychiatric treatment was one of the primary reasons for dissatisfaction in psychiatric facilities. Participants said that factors, including being compelled to work in mental hospitals, unsuitable working circumstances, patients’ little rehabilitation, and a lack of nursing awareness required for working in PWs were involved in their dissatisfaction. According to previous research, which confirms these findings, nurses recruited to work in psychiatric wards had to start immediately due to a staffing crisis and did not attend an appropriate ward orientation training course [40].
Another research revealed that the majority of PNs would leave the field within the first year after their graduation, owing to issues, such as a high workload, an unclear career path, and a dearth of expert physicians [29]. Additionally, PNs had more favorable opinions regarding working in mental wards when they had stronger professional ties with patients [41].
Regarding the importance of education in determining students’ and nurses’ employment interests, in order to pique their interest, it is important to educate them well on the knowledge and abilities needed for psychiatric nursing practice. Nurses’ interest in employment in mental health departments can also be increased by using experienced nurses to supervise and guide new nurses. According to a previous study, enhancing nursing students’ practical and theoretical knowledge was helpful in fostering favorable attitudes about mental nursing [42].
Contrarily, some researchers discovered that most students have a favorable attitude toward those who suffer from mental disorders and are pleased with their training for a career in psychiatric nursing [43]. These results conflict with those of the current study, and this discrepancy may be explained by the study’s unique environment.
A negative reputation for PNs in the public was the second major component of the reasons for nurses’ dissatisfaction with working in mental wards. Participants reported that their DSS was influenced by their poor prior experiences with mental nursing as well as the unfavorable opinions of their relatives and coworkers against PNs [44]. Based on research findings, psychiatric nursing has been struggling with a poor status for a long time. Additionally, the issue of associative stigma has been researched by several academics throughout the world [28].
The fact that many individuals have preconceived notions about those who work with these clients may further contribute to the poor prestige of the PN profession, thereby diminishing their desire to work in mental wards [45]. These attitudes may affect the behavior of nurses, causing them to vent their anger on mentally ill patients who are subsequently seen as least deserving of support and nursing, reducing their motivation to work in PWs [46]. The morale and interest of nurses in working in mental wards are both significantly affected by unfavorable views toward PNs [46, 47].
Other studies found that PNs were reluctant to tell their friends and family about their jobs out of concern about social stigmatization [48]. Additionally, nurses’ morale is significantly affected and they become intensely preoccupied with their profession as a result of significant others’ unfavorable views and beliefs regarding patients with psychiatric illnesses and PNs. PNs are disproportionately affected by these issues, although nurses in other hospitals may feel more positively about their jobs at the beginning [49].
Bladon suggested that MHNs first pinpoint their distinctive qualities before showcasing them to the public [50] in order to lessen the associated stigma. The specific characteristics of PNs are that they utilize their understanding of addiction, mental illness, and mental health as the main topic that affects how they employ therapeutic relationships, holistic approaches, recovery, stigma reduction, and advocacy for system change. The development of the field and the training of additional health professionals may build on this distinctive feature [31]. 
The third major category in the current research was concerns of nurses. Participants said that their concern regarding patient abuse and their lack of experience with mental wards and patients considerably reduced their desire to work in such facilities. They, therefore, wanted to work in hospitals where they were neither afraid nor anxious. Another study conducted in Iraq found that new PNs were uninterested in working in mental wards because they were afraid of unforeseen events and suffering from psychiatric problems [51]. 
Another study showed that PNs are afraid to go to psychiatric wards and talk to patients [52]. Fear and stress are caused by patients’ aggression and irritability as well as nurses’ perceived inability to handle such patients [30]. Participants in this research claimed that their greatest anxieties were related to patient assaults, whereas nurses in other wards generally fear making mistakes or hurting patients. Because nursing students can think that people with psychiatric problems are harmful in any way, nursing students also have a phobia of visiting psychiatric units, so interventions are needed to help students develop favorable opinions about mental hospitals. Giving people the chance to participate in therapeutic encounters is an example of such an intervention [32].
Beginners and students should be educated about MHNs through theoretical studies and clinical practices to provide them with the information they need to make an informed decision about their ultimate career choice [53]. One strategy to address this concern is to include service users in lectures as part of the curriculum to reinforce attachment beliefs. 
The present study can help decision makers to maintain a fundamental step in promoting well-being by increasing job satisfaction by revealing health provider practices through their dissatisfaction with work in the mental health department.
The researchers used anecdotal and narrative qualitative research for those who had more than one year of experience with the participants because there were experiences not captured in quantitative research. It summarizes what is going on in the minds, which may not come out except with this approach. However, there are problems though, including conducting primary research may feel more like observation than research and regulatory issues may have made the search more complicated. It may have resulted in a lower response rate because MHNs did not want to reveal a lack of knowledge or emerging individual skills Also, inclusion to reach the reality of daily practice is sometimes incomplete and MHNs might not have revealed everything.

Conclusion
This study demonstrates that the primary factors contributing to nurses’ dissatisfaction while working in mental units are insufficient training for providing psychiatric treatment, a negative reputation for PNs in the public, and nurse concerns. When faced with no other alternatives, PNs prefer to work in psychiatric facilities despite their lack of training and experience in these settings. Their participation in providing nursing care in PW is also influenced by the opinions of family and colleagues, their previous experiences in this field, and their concerns about patient violence. 
The results can help policymakers understand the reasons for nurses’ dissatisfaction while working in PWs, which allows them to make new adjustments in their training and raise the standard of treatment. To increase nurses’ awareness of quality patient care, they can develop and implement a formal program that focuses on clinical supervision and a practice environment that is informed by assessment. To foster a culture of continuous learning, they also allow nurses to attend more classes and practice sessions during work hours. Media-based initiatives are also needed to change public perceptions of people with mental health problems and the healthcare professionals who treat them. These initiatives may increase nurses’ willingness to work in psychiatric wards and increase the level of care they provide.
The findings of the present study, which show the first-hand experiences of nurses about the causes of dissatisfaction during work in mental hospitals, can complement the few studies done in this field. The emphasis of this study on the components and effective factors in nurses’ dissatisfaction while working in psychiatric wards makes it useful for developing a tool to measure nurses’ views in this field. As a result, investigations using mixed methods or tools designed for the assessments of the reasons for PNs’ dissatisfaction are advised. Additionally, it is advised to do research with other nurses in different wards.

Ethical Considerations
Compliance with ethical guidelines
This study was authorized by the Ethics Committee of the College of Nursing at the University of Babylon in Iraq (No.: 2799 Dated 2021-2022). Participants were given explicit explanations of the study’s purpose, and interviews were conducted in accordance with their preferences. They received guarantees regarding the privacy of personal data, their freedom to access the research conclusions, and their ability to voluntarily leave the study at any time. The authorities at the research location granted the necessary approvals for the study. All subjects gave their written informed consent before starting the study because they were all over 20 years old.

Funding
This research was part of a PhD thesis of Firas Al-aboudy, approved by Department of Mental Health Nursing, University of Babylon (Grant No.: 2799, dated 2021-2022).

Authors' contributions
Data collection, data analysis, and drafting the manuscript: Firas Al-aboudy; Review, supervision, and final approval: Hasan Alwan Baiee.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to take this opportunity to thank the Dean, the Scientific Assistant, all of the faculty’s professors and administrators, as well as all the nurses who helped out with the study.

References

1. Liberati E, Richards N, Willars J, Scott D, Boydell N, Parker J, et al. A qualitative study of experiences of NHS mental healthcare workers during the Covid-19 pandemic. BMC Psychiatry. 2021; 21(1):250. [DOI:10.1186/s12888-021-03261-8] [PMID] [PMCID]
2. Samari E, Seow E, Chua BY, Ong HL, Lau YW, Mahendran R, et al. Attitudes towards psychiatry amongst medical and nursing students in Singapore. BMC Medical Education. 2019; 19(1):91. [DOI:10.1186/s12909-019-1518-x] [PMID] [PMCID]
3. Markiewicz-Gospodarek A, Górska A, Markiewicz R, Chilimoniuk Z, Czeczelewski M, Baj J, et al. The relationship between mental disorders and the COVID-19 pandemic-course, risk factors, and potential consequences. International Journal of Environmental Research and Public Health. 2022; 19(15):9573. [DOI:10.3390/ijerph19159573] [PMID] [PMCID]
4. Sedighi E, Bidaki R, Meidani A, Ahmadinia H, Rezaeian M. [Mental health status in medical students of Rafsanjan University of Medical Sciences in 2016 (Persian)]. Journal of Rafsanjan University of Medical Sciences. 2018; 17(7):669-80. [Link]
5. Rahmani N, Mohammadi E, Fallahi-Khoshknab M. Nurses' experiences of the causes of their lack of interest in working in psychiatric wards: A qualitative study. BMC Nursing. 2021; 20(1):246. [DOI:10.1186/s12912-021-00766-1] [PMID] [PMCID]
6. Bakhtiari Shahri S. The relationship between mental pressure and job burnout of nurses working in the centers of mentally disabled adults. Iranian Rehabilitation Journal. 2012; 10(3):26-9. [Link]
7. Ghadimianfar M, Dadkhah A. Prediction of rehabilitation nurses’ psychological well-being by personality traits and defense mechanisms. Iranian Rehabilitation Journal 2015; 13(4):40-48. [Link]
8. Plana-Ripoll O, Pedersen CB, Agerbo E, Holtz Y, Erlangsen A, Canudas-Romo V, et al. A comprehensive analysis of mortality-related health metrics associated with mental disorders: A nationwide, register-based cohort study. Lancet. 2019; 394(10211):1827-35. [DOI:10.1016/S0140-6736(19)32316-5] [PMID]
9. Kilbourne AM, Beck K, Spaeth-Rublee B, Ramanuj P, O'Brien RW, Tomoyasu N, et al. Measuring and improving the quality of mental health care: A global perspective. World Psychiatry. 2018; 17(1):30-8. [DOI:10.1002/wps.20482] [PMID] [PMCID]
10. De Oliveira SM, de Alcantara Sousa LV, Gadelha M do SV, do Nascimento VB. Prevention actions of burnout syndrome in nurses: An integrating literature review. Clinical Practice and Epidemiology in Mental Health. 2019; 15:64. [DOI:10.2174/1745017901915010064] [PMID] [PMCID]
11. Foster K, Roche M, Delgado C, Cuzzillo C, Giandinoto JA, Furness T. Resilience and mental health nursing: An integrative review of international literature. International Journal of Mental Health Nursing. 2019; 28(1):71-85. [DOI:10.1111/inm.12548] [PMID]
12. Samartzis L, Talias MA. Assessing and improving the quality in mental health services. International Journal of Environmental Research and Public Health. 2019; 17(1):249. [DOI:10.3390/ijerph17010249] [PMID] [PMCID]
13. Lora A, Hanna F, Chisholm D. Mental health service availability and delivery at the global level: An analysis by countries' income level from WHO's Mental Health Atlas 2014. Epidemiology and Psychiatric Sciences. 2017; 1-12. [DOI:10.1017/S2045796017000075] [PMID]
14. Ong HL, Seow E, Chua BY, Xie H, Wang J, Lau YW, et al. Why is psychiatric nursing not the preferred option for nursing students: A cross-sectional study examining pre-nursing and nursing school factors. Nurse Education Today. 2017; 52:95-102. [DOI:10.1016/j.nedt.2017.02.014] [PMID]
15. Holmberg C, Caro J, Sobis I. Job satisfaction among Swedish mental health nursing personnel: Revisiting the two-factor theory. International Journal of Mental Health Nursing. 2018; 27(2):581-92.[DOI:10.1111/inm.12339] [PMID]
16. Payne A, Koen L, Niehaus DJH, Smit IM. Burnout and job satisfaction of nursing staff in a South African acute mental health setting. The South African Journal of Psychiatry. 2020; 26:1454. [DOI:10.4102/sajpsychiatry.v26i0.1454] [PMID] [PMCID]
17. Li C, Yang F, Yang BX, Chen W, Wang Q, Huang H, et al. Experiences and challenges faced by community mental health workers when providing care to people with mental illness: A qualitative study. BMC Psychiatry. 2022; 22(1):623. [DOI:10.1186/s12888-022-04252-z] [PMID] [PMCID]
18. Tirgari B, Azizzadeh Forouzi M, Ebrahimpour M. Relationship between posttraumatic stress disorder and compassion satisfaction, compassion fatigue, and burnout in Iranian Psychiatric Nurses. Journal of Psychosocial Nursing and Mental Health Services. 2019; 57(3):39-47. [DOI:10.3928/02793695-20181023-02] [PMID]
19. Huang X, Wang L, Dong X, Li B, Wan Q. Effects of nursing work environment on work-related outcomes among psychiatric nurses: A mediating model. Journal of Psychiatric and Mental Health Nursing. 2021; 28(2):186-96. [DOI:10.1111/jpm.12665] [PMID]
20. Namdari S, Nasiri A, Nakhaee S, Taheri F. Exploring the effects of nurses family-work conflict on patient care quality: A qualitative study. Modern Care Journal. 2019; 16(1):e86130. [DOI:10.5812/modernc.86130]
21. Gbeddy GA. Using mindfulness-based practice to reduce work-related stress and burnout among psychiatric nurses. Chapel Hill: The University of North Carolina; 2021. [Link]
22. Senek M, Robertson S, Ryan T, King R, Wood E, Taylor B, et al. Determinants of nurse job dissatisfaction - findings from a cross-sectional survey analysis in the UK. BMC Nursing. 2020; 19:88. [DOI:10.1186/s12912-020-00481-3] [PMID] [PMCID]
23. Goodwin J, Kilty C, Harman M, Horgan A. "A great stress among students" - mental health nurses' views of medication education: A qualitative descriptive study. Nurse Education Today. 2019; 77:18-23. [DOI:10.1016/j.nedt.2019.03.005] [PMID]
24. Saquib N, Zaghloul MS, Saquib J, Alhomaidan HT, Al-Mohaimeed A, Al-Mazrou A. Association of cumulative job dissatisfaction with depression, anxiety and stress among expatriate nurses in Saudi Arabia. Journal of Nursing Management. 2019; 27(4):740-8. [DOI:10.1111/jonm.12762] [PMID]
25. Bartova Z. Learning from the experts: Qualitative study of the lived experience of mental illness [PhD thesis]. Joondalup: Edith Cowan University; 2014. [Link]
26. Al-Enezi N, Chowdhury RI, Shah MA, Al-Otabi M. Job satisfaction of nurses with multicultural backgrounds: A questionnaire survey in Kuwait. Applied Nursing Research. 2009; 22(2):94-100. [DOI:10.1016/j.apnr.2007.05.005] [PMID]
27. Rabiu-Akewusola T. Job satisfaction, work environment, job stress, and professional identity among psychiatric nurses[PhD thesis]. Minneapolis: Walden University; 2020. [Link]
28. Waddell C, Graham JM, Pachkowski K, Friesen H. Battling associative stigma in psychiatric nursing. Issues in Mental Health Nursing. 2020; 41(8):684-90. [DOI:10.1080/01612840.2019.1710009] [PMID]
29. Jiang F, Zhou H, Rakofsky J, Hu L, Liu T, Wu S, et al. Intention to leave and associated factors among psychiatric nurses in China: A nationwide cross-sectional study. International Journal of Nursing Studies. 2019; 94:159-65. [DOI:10.1016/j.ijnurstu.2019.03.013] [PMID]
30. Sim IO, Ahn KM, Hwang EJ. Experiences of psychiatric nurses who care for patients with physical and psychological violence: A phenomenological study. International Journal of Environmental Research and Public Health. 2020; 17(14):5159. [DOI:10.3390/ijerph17145159] [PMID] [PMCID]
31. Yanchus NJ, Periard D, Osatuke K. Further examination of predictors of turnover intention among mental health professionals. Journal of Psychiatric and Mental Health Nursing. 2017; 24(1):41-56. [DOI:10.1111/jpm.12354] [PMID]
32. Oates J, Drey N, Jones J. 'Your experiences were your tools'. How personal experience of mental health problems informs mental health nursing practice. Journal of Psychiatric and Mental Health Nursing. 2017; 24(7):471-9. [DOI:10.1111/jpm.12376] [PMID]
33. Wildemuth BM. Applications of social research methods to questions in information and library science. Santa Barbara: Abc-Clio Publishing; 2016. [Link]
34. Polit DF, Beck CT. Essentials of nursing research: Appraising evidence for nursing practice. Philadelphia: Lippincott Williams & Wilkins; 2014. [Link]
35. Qi W, Sheng M, Shi Z. Professional identity and its work-related factors among psychiatric nurses: A cross-sectional study. Japan Journal of Nursing Science. 2021; 18(1):e12380. [DOI:10.1111/jjns.12380] [PMID]
36. Miyata H, Kai I. Reconsidering evaluation criteria for scientific adequacy in health care research: An integrative framework of quantitative and qualitative criteria. International Journal of Qualitative Methods. 2009; 8(1):64-75. [DOI:10.1177/160940690900800106]
37. Stephens S. Qualitative content analysis: A framework for the substantive review of hospital incident reports. Journal of Healthcare Risk Management. 2022; 41(4):17-26. [DOI:10.1002/jhrm.21498] [PMID]
38. Sabetsarvestani P, Mohammadi F, Tehranineshat B, Bijani M, Fereidouni Z. Barriers to efficient management of in-home care: A qualitative content analysis. Nursing Open. 2022; 9(2):1200-9. [DOI:10.1002/nop2.1161] [PMID] [PMCID]
39. Jaroslaw Kriukow. Qualitative coding and thematic analysis in Microsoft Word [Internet]. 2020 [Updated 2023 October 3]. Available from: [Link]
40. Traverse M, Chong J, Sutherland JL. Nursing student experiences with the mental health population: A scoping review of qualitative and quantitative evidence. Issues in Mental Health Nursing. 2022; 43(6):568-77. [DOI:10.1080/01612840.2021.2003491] [PMID]
41. Eldal K, Natvik E, Veseth M, Davidson L, Skjølberg Å, Gytri D, et al. Being recognised as a whole person: A qualitative study of inpatient experience in mental health. Issues in Mental Health Nursing. 2019; 40(2):88-96. [DOI:10.1080/01612840.2018.1524532] [PMID]
42. Kunst EL, Mitchell M, Johnston AN. Using simulation to improve the capability of undergraduate nursing students in mental health care. Nurse Education Today. 2017; 50:29-35.[DOI:10.1016/j.nedt.2016.12.012] [PMID]
43. Happell B, Platania-Phung C, Bocking J, Scholz B, Horgan A, Manning F, et al. Nursing students' attitudes towards people diagnosed with mental illness and mental health nursing: An international project from Europe and Australia. Issues in Mental Health Nursing. 2018; 39(10):829-39. [DOI:10.1080/01612840.2018.1489921] [PMID]
44. López-López IM, Gómez-Urquiza JL, Cañadas GR, De la Fuente EI, Albendín-García L, Cañadas-De la Fuente GA. Prevalence of burnout in mental health nurses and related factors: A systematic review and meta-analysis. International Journal of Mental Health Nursing. 2019; 28(5):1032-41. [DOI:10.1111/inm.12606] [PMID]
45. Yang J, Tang S, Zhou W. Effect of mindfulness-based stress reduction therapy on work stress and mental health of psychiatric nurses. Psychiatria Danubina. 2018; 30(2):189-96. [DOI:10.24869/psyd.2018.189] [PMID]
46. Townsend MC, Morgan KI. Psychiatric mental health nursing: Concepts of care in evidence-based practice. Philadelphia: F. A. Davis Company; 1999. [Link]
47. Muir-Cochrane E, O'Kane D, Oster C. Fear and blame in mental health nurses' accounts of restrictive practices: Implications for the elimination of seclusion and restraint. International Journal of Mental Health Nursing. 2018; 27(5):1511-21. [DOI:10.1111/inm.12451] [PMID]
48. Bilge A, Palabiyik O. The effect of short films about mental health and disorders on preventing stigmatization in nursing education. Archives of Psychiatric Nursing. 2017; 31(1):88-92. [DOI:10.1016/j.apnu.2016.09.006] [PMID]
49. Chambers M. Psychiatric and mental health nursing: The craft of caring. Milton Park: Taylor & Francis; 2017. [Link]
50. Bladon H. Out of the shadows: De-medicalising mental health nursing. Mental Health Practice. 2017; 20(9):15-20. [DOI:10.7748/mhp.2017.e1187]
51. Mohamed EH, Al-Juboori AKK. Job satisfaction among nurses ‘ in baghdad psychiatric hospitals. Journal of the College of Basic Education. 2010; 15(64):201-6. [Link]
52. Hagen J, Knizek BL, Hjelmeland H. Mental health nurses' experiences of caring for suicidal patients in psychiatric wards: An emotional endeavor. Archives of Psychiatric Nursing. 2017; 31(1):31-7. [DOI:10.1016/j.apnu.2016.07.018] [PMID]
53. Hwang B, Choi H, Kim S, Kim S, Ko H, Kim J. Facilitating student learning with critical reflective journaling in psychiatric mental health nursing clinical education: A qualitative study. Nurse Education Today. 2018; 69:159-64. [DOI:10.1016/j.nedt.2018.07.015] [PMID]