Participant characteristics
The sample size followed the principle of information saturation. Finally, fourteen participants were recruited from September to October 2020, including ten nurses (No. N1~N10) and four doctors (No. D1~D4). Participants ranged from 31 to 51 years old (mean age of 39.36 years), and they had worked in trauma-related fields for a duration of 15.57 years (range: 5 years to 33 years). The detailed characteristics of the participants are shown in Table 1.
Table 1 Characteristics of the participants (n=14)
No
|
Gender
|
Age
(years)
|
Working years
|
Years of work in the trauma field
|
Department
|
Educational background
|
Professional title
|
D1
|
Male
|
44
|
20
|
15
|
orthopedics
|
undergraduate
|
visiting staff
|
D2
|
Male
|
35
|
8
|
8
|
traumatic burn department
|
master
|
visiting staff
|
D3
|
Male
|
48
|
24
|
24
|
orthopedics
|
doctor
|
visiting staff
|
D4
|
Male
|
34
|
8
|
5
|
emergency trauma department
|
undergraduate
|
visiting staff
|
N1
|
Female
|
39
|
20
|
10
|
emergency trauma department
|
undergraduate
|
associate professor of nursing/head nurse
|
N2
|
Female
|
38
|
15
|
5
|
emergency trauma department
|
undergraduate
|
intermediate nurse
|
N3
|
Female
|
51
|
33
|
33
|
orthopedics
|
undergraduate
|
professor/head nurse
|
N4
|
Female
|
38
|
19
|
19
|
traumatology department
|
undergraduate
|
intermediate nurse
|
N5
|
Female
|
37
|
18
|
18
|
traumatology department
|
undergraduate
|
intermediate nurse
|
N6
|
Female
|
31
|
17
|
13
|
orthopedics
|
undergraduate
|
intermediate/head nurse
|
N7
|
Female
|
40
|
17
|
17
|
emergency department
|
undergraduate
|
intermediate/head nurse
|
N8
|
Female
|
43
|
23
|
23
|
orthopedics
|
junior college
|
intermediate nurse
|
N9
|
Female
|
39
|
16
|
16
|
orthopedics
|
undergraduate
|
intermediate nurse
|
N10
|
Male
|
34
|
12
|
12
|
emergency department
|
undergraduate
|
intermediate nurse
|
Themes
Four main themes concerning psychological care for patients by medical staff were identified based on the data and TPB: attitude, subjective norms, perceptual behaviour control and demands. The domains of the four themes are presented in detail in Figure 1. Based on the theory of planned behavior, attitude in this study refer to the cognition and evaluation of medical staff in providing psychological care for trauma patients. Subjective norms reflect the views and influences of hospital and family members for medical staff in implementing psychological care for trauma patients. Perceptual behavioral control refers to the medical staff's perception of difficulty or ease in carrying out psychological care for trauma patients, reflecting the actual control of medical staff in carrying out this behaviour. Demands refer to the suggestions and needs of medical staff in the process of carrying out psychological care.
Theme 1: Attitude
Most clinical nurses attached importance to psychological care and took the initiative to provide basic and broad psychological care for trauma patients in clinical practice. This was beneficial for the patients to relieve stress, improve cooperation and compliance with treatment, promote recovery, and gain mutual trust. However, they also mentioned that psychological care required more related professional knowledge and competencies, which led to increased workload. Moreover, the psychological care might not take effect immediately, which might affect the passion of the implementers.
Beliefs in Advantages
Potential benefits for medical staff and patients promoted their positive attitudes, including formation mutual trust, adherence to therapy, and recovery promotion.
A total of 28.57% interviewees (n=4) said that appropriate and timely psychological care by medical staff could help patients find their real problems and needs, assist them with role change, and establish mutual trust.
N2: "It was important to establish trust with the patients. We could provide a comfortable environment, gentle operation, friendly language, and use video news and other media to divert patients' fretful attention."
N6: "Psychological care could be reflected in the full exchange and communication with patients, then it was conducive to establish a good relationship with patients."
A total of 35.71% interviewees (n=5) mentioned that psychological care could let patients correctly cope with the impact of the trauma and improve their treatment compliance.
D2: "Some trauma patients undergo great pressure and have difficulty falling asleep before surgery. Through the verbal communication of doctors, the information support provided by nurses and the company of family members, they could gradually fall asleep."
D4: "The patient was able to follow the instructions of the medical staff, such as positioning and taking medication regularly."
Receiving psychological care could alleviate patients' negative emotions, reduce pressure, increase confidence in treatment, and promote their successfully return to society (n=5).
N7: "After psychological counselling, patients could face the condition well, cooperate with treatment and nursing, and promote they return to society as soon as possible after recovery.
N9: "Patients were less anxious and cooperated actively with our treatment. Sleep, diet and metabolism recovered quickly, which might help shorten the treatment process."
Beliefs in Disadvantages
Potential disadvantages contribute to negative attitudes among participants, including increasing workload, reflecting into short-term ineffective psychological care, and practising unconfidently.
More than half of the interviewees (n=8) believed that trauma occurred suddenly and urgently, which would cause great physical and mental impacts on patients. Trauma patients might depend strongly on medical staff and families, which requires medical staff to devote more energy and attention to them.
N5: "After injury, the patient strongly wished for his family to be around him and longed for the meticulous care of medical staff."
D2: "Everyone (medical staff) was busy. Offering psychological care would increase the workload."
Only three interviewees (n=3) mentioned that the psychological care process might be time-consuming and laborious, and could not be effective in the short-term.
D2: " The exact effect of psychological care might not be seen immediately, so it would not be done as detailed as the beginning."
Due to insufficient psychological care-related knowledge, the skill of carrying out psychological care was still relatively singular. Half of the interviewees (n=7) mentioned that they had no ability to implement comprehensive, in-depth, systematic and personalized psychological care for trauma patients.
N5: "We could do not much. It stayed at the level of health education, functional guidance and medical information. One-sided verbal comfort was the most common."
N6: "The clinical experience and educational level of nurses was uneven. Most nurses with psychological care qualifications were concentrated in the psychiatric department. The psychological care professional degree of nurses in the trauma ward was generally not high."
Theme 2: Subjective norms
Subjective norms originated from a person's beliefs about whether important referents approve or disapprove of them carrying out the behaviour (normative beliefs, e.g., other medical staff would support me performing psychological care).
Normative Beliefs -Supportive
The medical staff considered recognition by leaders and managers to be the most salient referents supportive of their performing psychological care. Other supportive referents were nursing culture guidance, patient's positive feedback, and the requirement of the families.
At present, the implementation of psychological care for trauma patients has gradually been valued and advocated by hospital managers. Eleven interviewees said that leaders carried out physical and mental care for trauma patients in the form of organizing expert lectures, building up volunteer service teams, setting up multidisciplinary collaboration teams, and conducting surveys on patients' psychological conditions. This also encouraged interviewees to take the initiative to carry out psychological care.
N5: "Our hospital launched the physical and mental care case sharing contest, which contributed to establishing a humanistic care group aiming to mutually exchange of psychological care methods."
Nursing culture advocates the implementation of physical and mental holistic care for patients and fully embodies humanistic care. Sympathy and responsibility for the patients are rooted in the medical staff. Four interviewees believed that driven by this nursing culture and sense of responsibility, they would take the initiative to care for patients' psychological conditions.
N3: "The basic moral character and duty of the medical staff was to relieve the pain of the patients, provide care and companionship, which was obligatory."
Two interviewees expressed that the positive affirmation and feedback of trauma patients on psychological care and the establishment of an interactive relationship between medical staff and patients would make the implementers feel professional value and sense of achievement, and motivate them to carry out psychological care.
N5: "After communication, patients took the initiative to greet us and offered us the feelings feedback on the process of care, we would feel a sense of achievement."
N8: "Psychological problems of patients could be relieved, they realized that nurses did not just give injections and infusion, we also embodied our professional values."
Only one respondent reported that family attention to the psychological status of trauma patients would also determine the behaviour norms of medical staff.
N1: "It was an urgent need for family to help patients establish confidence in recovery when they encounter trauma."
Normative Beliefs -Unsupportive
The medical staff believed that not having none targeted and operable procedures by leaders and managers to be the most salient referents unsupportive of performing psychological care. Participants identified inconsistent cooperation originating from colleagues and patient's priorities to receive other support rather than psychological care as unsupportive factors.
All interviewees (n=14) indicated that managers had not yet formulated targeted and operable procedures and norms, so medical staff could not take timely assessment and reasonable treatment when facing the psychological conditions of trauma patients, which greatly limited the effective implementation of psychological care.
N6: "There was no professional assessment of the effectiveness of psychological care, and there was also no clear specification of what psychological care contains."
D4: "We did not have specific psychological care measures, so we did not know whether to comfort or persuade patients."
The implementation of psychological care was a long process, and inconsistent cooperation between colleagues for the same trauma patient would affect its development.
N2: " There was a lack of consistency in psychological care, and the successor nurse did not know the extent and specific content of the shift nurse's implementation of psychological care for patients."
Over half of interviewees (n=8) mentioned that some trauma patients would reject and resist sudden changes in the environment and treatment process, and they would show emotions such as rejection, unacceptability, self-denial, and fear. Some interviewees (n=6) believed that especially in the posttraumatic period, patients might be more concerned about the impact of trauma on their physical function, social survival, and later rehabilitation. Psychological care was not the patient's primary need, which made medical staff lack motivation to implement it.
N5: "When patients suddenly injured, they would deny and resist at first, avoid recalling the injury scene."
N8: "The patient most worried about his trauma condition. Sometimes when you were doing psychological care, he was not willing to talk with you. He felt that you hadn't really mentioned what he wanted to know."
Theme 3: Perceptual behaviour control
Control Beliefs -Facilitators
Participants noted that education or training experiences encouraged psychological care. When trauma patients exhibited psychiatric and psychological symptoms, their particular psychological condition was reflected in the nursing records of nurses, and the medical records of doctors, as a prompt reminder, was considered a motivator to encourage psychological care. Offering trauma patients access to professional psychologists was also one of the facilitators to benefit psychological care. In addition, participants noted that psychological care was, as one of the researches focuses, positively oriented in performing psychological care.
A total of 64.29% interviewees (n=9) affirmed that professional and systematic psychological knowledge and skills training has a certain role in promoting the implementation of psychological care. This experience helped performers exchange ideas, master certain psychological care methods, and facilitate the provision of targeted care for patients. In addition, half of the interviewees (n=7) said they had been exposed to psychology-related courses at school, which could potentially lead them to consider patients' psychological conditions in their clinical practice.
N7: "Inviting professional psychological trainers to carry out lectures could promote medical staff's understanding and experience of psychological care, which was conducive to its better application in clinical practice in the future."
D1: "Through learning some psychology-related courses in the school, medical staff had a certain understanding of psychological care. Afterwards, they would have the awareness to implement psychological care when the patients might need it."
The psychological characteristics and requirements of different trauma patients varied greatly, which would cause confusion to implementers. Most interviewees (n=12) believed that psychological care might be more effective when it could be conducted by psychology professionals.
N9: "After simple screening with the scale, patients with psychological problems would receive guidance from the psychologist and pharmacist."
D1: "With these patients who had some psychological problems or obstacles, we generally sought professional psychologists for consultation and guidance."
Four interviewees mentioned that trauma easily caused physical and mental harm to patients, and when patients were in negative emotional states or behaviours, it promoted medical staff to pay more attention to patients' psychological conditions.
N7: "Patients might express delusions, hallucinations and suicidal tendencies when they experienced too severe traumatic events or scenes, which would prompt us to strengthen the judgement and observation of patients' physical and mental conditions."
N10: "Young people or unmarried people with an impaired physical image might experience mood disorders. They could be at risk for depression or suicide and should be closely cared for by medical staff."
Five interviewees pointed out that the abnormal psychological condition of patients and the counselling and disposal by medical staff would be noted in the nursing records of nurses and medical records of doctors, or the special situation might be highlighted during a shift meeting, which could remind the medical staff to improve the patient's bad psychological condition.
N8: "If the patient had a special psychological condition, we would describe it in the nursing records."
N9: "We would reflect the psychological status of patients in the nursing records, and paid attention to the effect of psychological counselling."
Three interviewees mentioned that psychological care was one of the focuses for researchers. Medical staff could deepen their cognition of psychological care, stimulate interest and apply the research output to clinical practice by exploring related research.
N1: "From the past to now, psychological care had always been mentioned. It was of great significance for nurses to carry out psychological research."
Control Beliefs – Barriers
Unsystematic award or penalty mechanisms were discussed by the medical staff as barriers to performing psychological care. Other frequently nominated barriers included insufficient time or energy and scattered recourses of understanding psychological care. Distraction and forgetting were also mentioned as barriers.
Almost half of interviewees (n=6) mentioned that missing standardized supervision and reward mechanisms at the management level would cause psychological care performers to gradually lose enthusiasm, which could hinder the effective development of psychological care.
N6: "The implementation of psychological care was more like the duty of nurses, without practical incentives, nurses would gradually lose the enthusiasm to carry out it."
D1: "We were encouraged to do psychological care, but there was no compensation for this project, and there was also no evaluation index after the implementation, which would affect the enthusiasm of the implementers."
Clinical practice is complicated and busy. All the interviewees showed that the lack of human resources greatly restricted the continuous and detailed development of psychological care. Medical staff might have insufficient time or energy to perform psychological care after ensuring that their routine work was completed.
N6: "Nurses did not have leisure time to get out of their trivial routine work."
Nine interviewees believed that the relevant knowledge and skills acquired through school courses or intensive psychology-related learning organized by the hospital were scattered. The training time was usually fragmented (such as several times a week), and the theoretical knowledge was not closely connected with the practical application. Therefore, these scattered resources made it difficult for performers to truly master the psychological care related-knowledge and apply for clinical practices.
N2: "Infrequent systematic training might be organized once or twice a year indeed, the impression after learning was not deep."
N5: "It was difficult for medical staff to get systematic understanding and clinical practice application by arranged several trainings of psychological care in scattered time."
Only one interviewee mentioned that nursing staff would arrange the priority of tasks according to the nursing plan. When patients did not show significant psychological problems and their daily tasks were heavy, the implementation of psychological care might be deprioritised or forgotten.
N6: "There was many basic jobs to be done for medical staff. When the implementation of psychological care was not the primary task for them, this work was easy to ignored."
Theme 4: Demands
The following demands were desired to be supported for medical staff: diversification of training, establishment of operational norms, ensuring abundant staffing, promotion of psychology-related multidisciplinary cooperation and cooperation with family members.
The interviewees thought that diversified training forms and contents were the basis and key to implementing psychological care. Nine interviewees said that operability, normative and targeted psychological care procedures and norms should be established.
N3: "It was necessary to clarify the scope of application of the norms and consider whether different levels of hospitals and nurses could accept or not. "
N6: "The offline and online training methods could be carried out simultaneously, which was convenient for later medical staff to flexibly arrange time for review."
Most interviewees (n=12) suggested that adequate and reasonable staffing should be provided.
N6: "Advocating or encouraging medical staff to offer psychological care to patients should be combined with the current manpower."
A total of 85.71% of interviewees (n=12) suggested that systematic and targeted psychological care required high professional skills, and multidisciplinary team assistance could be considered when patients had significant psychological problems and significant needs.
N3: "If the nurse did not have abundant psychological knowledge and skills after the problem was found, she should learn to play the team advantage."
Two interviewees mentioned that psychological care needs to mobilize the patient's support system and pay attention to continuity.
N1: "The support of families to patients could not be replaced by medical staff. Psychological care should not only stay in the hospital, but it should continue after discharge."