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NURSING STUDENTS’ BARRIERS IN CARING FOR SCHIZOPHRENIA PATIENTS WITH VIOLENCE RISK

Background: There is a general consensus that schizophrenia patients have a greater risk to become violent. Caring for schizophrenia patients with risk of violence presents difficult clinical challenges, and it complicates the efforts of nursing student. Analysis of nursing student' barriers may lead to improve nursing management of risk of violence. Objective: The aim of this study is to explore the nursing student barriers in for caring schizophrenia patients with violence risk. Method: A total sample of 22 nursing students completed their experience through reflective diary during clinical placements. The qualitative data were explored by thematic content analysis method using NVivo. Results: Three themes were emerged from the data included: emotions, personal experience, and inadequate communication skills. Conclusion: These themes reflected the barrier of the nursing students when they applied nursing care toward schizophrenia patient with violence risk. Knowing the barriers is very important for successful violence risk management for nursing student.


INTRODUCTION
Violence among adults with schizophrenia follows two distinct pathways that are associated with antisocial conduct, acute psychopathology of schizophrenia. 1 Violence in people with serious mental illness probably results from multiple risk factors in several domains. 2 Although there is a relatively small percentage of psychiatric patients who are violent, evidence from a number of studies indicates that certain subgroups of psychiatric patients, including patients who abuse substance, have psychoses, and are non-adherent to treatment, are at a greater-than-normal risk of being violent. 3 A systematic review and meta-analysis about schizophrenia and violence showed that there was a modest but a statistically significant increase of risk of violence in schizophrenia with an odds ratio (OR) of 2.1 (95% confidence interval [CI] 1.7-2.7) without co morbidity, and an OR of 8.9 (95% CI 5.4-14.7) with co morbidity with substance abuse. 4 Stigma in caring schizophrenia with violence risk might be fearful by nursing student at their first clinical placement. This is consistent with the research findings, assaults by psychiatric patients that contribute to the stigma of mental illness. 5 The patient populations more likely to become violent and the mental healthcare staff at the greatest risk of becoming their victims. 6 Assaults by patients and families are likely to be directed towards young physicians who are early in their medical careers. 7 The challenge for medical practitioners is to remain aware that some of their psychiatric patients do, in fact, pose a small risk of violence, while not losing sight of the larger prospective-that most people who are violent are not mentally ill and most people who are mentally ill are not violent. 2 Caring of schizophrenia patient with risk for self-directed violence, or risk for violence directed at others, is clinical challenges for nursing student in their first clinical placement. Nursing interventions in this regard can be thought in a continuum range from preventive strategies (self-awareness, patient education and assertiveness training), anticipatory strategies (verbal and nonverbal communications). The nurse may need to implement crisis management techniques and containment strategies such as seclusion or restraints. Nursing intervention with anger management toward schizophrenia patient with risk of violence in the ward usually consisted of starting to establish a trusting relationship, help the patient identify anger, assure patient to control behavior with deep breathing exercise, anger energy releasing, teaching verbal expression of assertive behavior, anger control by spiritual guidance, and antipsychotic administration. Nursing staff may place too much emphasis on the control of violence through restraint, medication, and seclusion at the cost of examining means of prevention. 8 In the implementation of nursing care, firstly nursing student should establish a therapeutic relationship. The barrier of giving nursing care could inhibit the therapeutic process. It would create difficulty to reach the goal of nursing intervention. Therefore, this study was conducted to examine the barriers of nursing students in caring schizophrenia with violence risk through reflective diary.

Study design
It was a qualitative study using a phenomenological approach. This approach aimed to generate a description of experiences of participants as phenomena. 9 This paper describes content analysis of nursing student' narratives about barriers in caring schizophrenia with violence risk. Twenty-two nursing students were interviewed and asked to build their analysis, which included the constraints of being able to express 'self' in academic format, and the concern attaching a mark that reduced the authenticity of the submission. In this assignment, attempts were made to address potential writing difficulties.

Participants
A total participant of 22 nursing diploma students who underwent first clinical placement in a psychiatric hospital Ghrasia, Yogyakarta were recruited for this study. These participants consisted of 19 females and 3 males with a mean age of 20.5 years (SD, 0.5; range, 20 to 22 years). The inclusion criteria of the participants were the participants who had significant knowledge and experience in caring schizophrenia with violence risk.

Ethical considerations
Permission for this study was obtained from the Ethics Committee of Health Polytechnic Semarang. The students signed informed consent prior to the study. All of the research materials were handled exclusively by the researcher and no student names were associated with any final written materials.

Data collection
Semi structured face-to-face interview was conducted to collect the data in this study. The format of structured questions was explained to promote narrative writing. The students were arranged for a three-week clinical posting in a psychiatric hospital, Ghrasia Hospital in the fourth semester of the second year of a nursing program. They were asked to complete their narrative writing after nursing clinical practice. All of narrative writing was collected four days after the end of the three weeks of clinical practice. Nursing students answered the questions and rated their skill and knowledge in violence risk assessment and management. It included the questions about evaluating risk assessment, evaluation, psychosocial assessments, violence risk factors, goals and interventions, skill, and knowledge. To ensure the trustworthiness of the study, reflective diary was collected by researcher in the end of meetings and member checking of participants 10 were performed.

Data analysis
Data analysis was done using content analysis afforded a systematic approach for analyzing narrative texts into categories and making sense of the data that was adapted. 10 First, researcher went through the data and recorded a preliminary general message from students. Then, data were analyzed to identify similarities and differences between the messages, then unitized into phrases or sentences relating to specific topics. A code was assigned to a text chunk of any size that represented a single theme or issue of relevance by using NVivo (QSR International Pty Ltd., Doncaster, VIC, Australia) software. We categorized under specific codes from phrases or sentences formed through the reflective diaries of the students. Similar codes were collapsed into fewer, broader themes, and the final theme list emerged. The final theme list was shared with additional researchers to validate the first coding scheme created. General agreement in the coding process was reached and verbatim extracts were taken from the text to illustrate the content of each final study theme.

RESULTS
A total of 22 nursing students who underwent clinical placement in a psychiatric hospital participated in this study. The students demonstrated four common themes in reflective diaries, which included:

Emotions
The nursing students were experiencing fear and anxious in caring schizophrenia with violence risk during the clinical placement in the reflective diaries. They recalled the incidents that happened throughout the first clinical placement in the intensive psychiatric unit and in the maintenance ward. They shared their feeling in their first relationship with schizophrenic.
The students were encouraged to identify their own feeling, strength and weakness in their pre interaction phase. They also described unpleasant emotional responses of varying or unspecified intensity (e.g., related to fear and other feelings) that created difficulty. The nurses' narratives as the following: • "Fear, they will do physical abuse like splitting, hitting and verbal abuse." (Student C) • "I'm just afraid with the subject." (Student I) Some students were feared about asking the cause of violence history that might encourage violence acts, and did nothing while trying to figure out the impact of their anger. They said: Some students were able to recognize their weaknesses. They felt afraid about what they thought about patient, they were not able to start using themselves as a therapeutic tool. They got themselves more difficult in establishing trustee relationship and became empathic.
• "His command hallucination is still strong, he always talks too much and sometimes so silent, I am afraid if suddenly he hits me." (Student V)

Personal experience
In the second week, the nursing students shared their personal experiences through reflective diaries. They were asked to recall the incidents when applying nursing management to patients with violence risk. Nursing student drew on experience or lack of experience in their own family or personal life, and shared personal experiences. Some said that their reaction to violence risk impaired their ability to care of patients with violence risk. They said: Some nursing students identified that violence risk could be managed by religion, as the source of patient values, but others described spiritual or other beliefs that led them to remain calm, as their following statement: • "I had a chance to assist how to control anger with spiritual ways such as sholat." (Student E) • "I ever try to teach patient take a deep breath with dzikir istighfar they become irritable; they demonstrate it at that time but not practiced later. It became exhausted for me." (Student H)

Inadequate communication skills
Students in this study reflected on inadequate communication skills problems during an interactive session with violence risk patients. The students showed a barrier in their communication skills because patients easily get bored and lack of concentration. They emerged the data from the reflective diaries about their difficulties in caring patients with violence risk. Some nurses explained that they had lack of communication, and did not know what to say about a violence risk patient. They said: Nursing students also indicated that they had lack of skills and knowledge about violence risk assessment as their statements as following:

DISCUSSION
Nursing students play an increasingly active role in their first clinical practice. They would learn how to give nursing care for patient with violence risk, until they are capable to responsible for their patients. In learning process, nursing student should identify the barrier and strategic to solve it. The results demonstrated that the barriers of students from the academic to the clinical setting in caring patient with violence risk through reflective diaries.
One of the main barriers to open and therapeutic communications is the emotional barrier. The results showed that the nursing student's barrier focused much on their emotions during their first met with the patient. The students shared a various feeling, which ranged from their stigma until the fear and anxious as barrier in performing nursing problem skills. This stigma may led to sinister interpretation The findings are consistent with observation of the student's emotional response meeting with unfamiliar or new learning events. 11 The feeling phase gives the respondent an opportunity to explore their thoughts about the incident. 12 However, beliefs about professional roles and responsibilities, emotional vulnerability can restrict participation in caring violence risk patient.
Personal experience makes a distance from patient in therapeutic process. This barrier will break down the trustee relationship. Expectation and prejudices may lead to false assumption by putting patient in the different view. Empathic attitude should be used by nursing student rather than stereotype. A high level of honesty and acceptance when talking to the patient and responding to their concern is needed.
The results of this study showed that the inadequate communication skills were stressed by students in their reflective diaries. Students strived to obtain patient compliance during the treatment process through effective communication skills. When assessing risk, it is important to address the following issues: the patient's insight into his or her illness. 6 Lack of communication skill must be aware as barriers and nursing students should try to reduce their impact by continually checking understanding and by offering appropriate feedback.
The main weakness of the qualitative study is that not possible to make quantitative predictions. However, the strength of this research is to provide an understanding and description of nursing students' personal experiences of what barrier in caring schizophrenia with violence risk.

CONCLUSION
In conclusion, knowing nursing student barrier is shown to be important in clinical practice. A major benefit in this study is that the nursing students were being encouraged to develop individual strategy in learning and caring schizophrenia with violence risk. The students successfully identified their barriers while recognizing their individual learning needs through reflective diary. Nursing students' barriers in caring violence risk should be understood; therefore, a strategy to overcome the problem could be considered an integral part of professional practice in nursing education.

Declaration of Conflicting Interest
None declared.

Funding
This study was funded by Politeknik Kesehatan Kemenkes Semarang, Indonesia.