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Psychiatric nursing: Can education help it become more popular?
The literature pertaining to the career choices of undergraduate nursing students clearly demonstrates that psychiatric nursing falls very low on the list of priorities. While there is some evidence to suggest that education can produce a more positive view of the care of the mentally ill and/or psychiatric nursing, research which specifically addresses the impact of educational methods upon the popularity of psychiatric nursing has not been undertaken. This paper discusses the results of a research project which examined the relationship between the study of, and the popularity of, psychiatric nursing. The results of this quasi-experimental study suggest an increase in the popularity of psychiatric nursing occurred at the completion of a psychiatric nursing program. The potential impact of the use of problem-based learning as an educational technique is examined.
Problem-based Nursing students Attitudes Education Psychiatric nursing
Despite the stated aim of comprehensive undergraduate nursing education toproduce graduates capable of practice at beginning level in a broad range of health care settings, the literature demonstrates that students tend to exit their education program with a strong leaning towards medical-surgical nursing (Arnswald 1987; Carter 1986; Caroselli-Karinja 1988; Happell 1997; Peplau 1989). Working with children was also found to be popular in a recent Australian study (Stevens & Dulhunty 1992; 1994). Within the hierarchy of career preferences psychiatric nursing has consistently been demonstrated to be low on the list of studentsí priorities.
There is no conclusive evidence from the literature concerning the degree to which education can affect a change in the attitudes towards psychiatric nursing. There is some support in the research findings for the notion that educational exposure can create more positive attitudes towards the care of the mentally ill and the practice of psychiatric nursing (Bairan & Farnsworth 1989; Carter 1986; Collister 1983; Hafner & Proctor 1993; McLoughlin & Chalmers 1991; Proctor & Hafner 1991). The extent to which such attitudinal change will result in increased interest in psychiatric nursing as a future employment option cannot be determined from these results. The final stage of a longitudinal study conducted in New South Wales (Stevens & Dulhunty 1994) suggested that any such increase would be minor.
It might be concluded from the above research that nursing education has no role to play in 'saving' psychiatric nursing. The response of students to specific approaches to the teaching of psychiatric nursing was not however, the focus of this research. An extensive review of the literature produced little discussion of how students respond to the teaching of psychiatric nursing. Harrison (1991) describes student attitudes towards this area of practice as based on fear, primarily resulting from misconceptions about the mentally ill. While the main focus of this paper concerned clinical experience, the results are nevertheless relevant towards all aspects of teaching psychiatric nursing in general. This article supports the findings of Stevens and Dulhunty (1992) that neophyte-nursing students tend to view the mentally ill with fear and mistrust.
Stevens and Dulhunty (1992) argued that neophyte-nursing students are reflecting the views of the broader society towards the mentally ill. That society holds negative views towards the mentally ill as being dangerous and unpredictable is well supported in the (Bairan & Farnsworth 1989; Lipton 1983; Lopez 1991; McLoughlin & Chalmers 1991; Olade 1983; Sellick & Goodear 1985; Southgate 1993). In the light of such evidence there is no reason to believe that people about to commence a nursing program would hold substantially different views. Furthermore such views would undoubtedly influence the attitudes of undergraduate student nurses towards a career in psychiatric nursing.
In order to explain the lack of popularity of psychiatric nursing, the finger is often pointed at the make up of undergraduate nursing curricula. A review of undergraduate nursing courses operating in Victoria, Australia, (Happell 1997) revealed that the theory and practice of psychiatric nursing accounted for a relatively minor proportion of the total curriculum hours in most courses. It may be argued therefore that psychiatric nursingacademics simply don't have enough time to make have any significant impact upon the manner in which students view psychiatric nursing. While an increase in the presence of psychiatric nursing within undergraduate curricula would undoubtedly be desirable, is it reasonable to see this as the only solution? Does it mean that within the current climate there is simply no hope of improving the image of psychiatric nursing? The authors would suggest that while the fight to increase the presence of psychiatric nursing within undergraduate curricula should be continued, that other methods to improve the profile of this specialty should be explored.
Further criticisms of psychiatric nursing education within comprehensive curricula concern the content of such programs. The tendency for psychosocial aspects of nursing to be viewed as synonymous with the theory and practice of psychiatric nursing has been particularly highlighted (Allan 1992; Arnswald 1987; Brackenreg 1992; Brown 1992; Caroselli-Karinja et.al. 1988; Henderson 1990; OíBrien 1994; Usher 1994). The potential consequences being that the education process fails to provide adequate information concerning the assessment and care of persons experiencing psychiatric symptomatology (Caroselli - Karinja et.al. 1988; Henderson 1990; O'Brien 1994; Yonge & Hurling 1990). While there it is not intended to minimise the role psychosocial nursing skills play a role in psychiatric, or indeed all branches of nursing, they are a long way from representing the totality of psychiatric nursing practice. Insufficient exposure to the theory and practice specific to psychiatric nursing means that comprehensive nurses do not become sufficiently skilled in the identification of psychiatric disorders and the implementation of appropriate nursing interventions. Furthermore, students may become discouraged from considering psychiatric nursing as a future career option by their perceived lack of knowledge and confidence.
In short, psychiatric nursing academics find themselves faced with three main barriers when attempting to increase the popularity of psychiatric nursing as a future career option: negative attitudes to the mentally ill which students bring with them into the educational program; inadequate time allocated to the theory and practice of psychiatric nursing; and, the tendency for psycho-social nursing skills to be identified as psychiatric nursing content. These barriers may appear at times to be all consuming and insurmountable. However, in order that psychiatric nursing survive as a specialty of nursing solutions must be found.
As stated previously, research to examine the impact of educational techniques on the outcomes of undergraduate psychiatric nursing education has not been reported in the literature. A broader perspective upon nursing education suggests that problem-based learning (PBL) for example, has become a popular technique for nursing education. A review of the literature conducted in Australia (Creedy, Horsfall & Hand 1992) indicates that approximately 20% of nursing courses have adopted a PBL framework.
Furthermore, within 80% of courses, some aspects of PBL have been utilized.PBL as an educational approach has been used extensively in medical education. A comprehensive review of the literature (Vernon & Blake 1993) demonstrated that student satisfaction with this method is significantly higher in comparison to more traditional educational methods. The feedback from academics in relation to PBL is similarly positive. (Albanese & Mitchell 1993; Eisterstaedt, Barry & Glanz 1990).
Despite the widespread use of PBL within nursing curricula, little research has been conducted to examine its effectiveness. A quasi-experimental study (Lewis & Tamblyn 1987) revealed a higher level of satisfaction with this learning method, although it did not find evidence to suggest any significant differences in the theoretical knowledge of nursing students exposed to PBL. Similar results were obtained from an evaluation of a PBL curriculum in New Zealand (Horsburgh, Lynes & Oliver 1984). The PBL approach was described as '_exciting, rewarding for the teachers, the students became very actively involved in their own learning and the success of the learning was certainly seen in the clinical situation' (p.7).
The extent to which PBL has been adopted within psychiatric nursing and the degree of success of its usage is not well known. The results of an evaluation provide some suggestion that PBL can not only reduce the fear and distrust of students towards the mentally ill, but also it can facilitate an increase in their interest in psychiatric nursing (Happell 1998). The need for further exploration of the potential of PBL to enhance the popularity of psychiatric nursing amongst undergraduate nursing students was identified in this paper. It was in response to this identified need that the current paper was written.
In order to ascertain the impact of a PBL psychiatric nursing learningprogram upon the attitudes of undergraduate nursing students towards psychiatric nursing as a future career option, a quasi-experimental study was undertaken. A time-series design was implemented to enable the comparison of pre- and post- test rankings of psychiatric nursing to be compared.
This study was conducted with undergraduate nursing students at a university in Victoria. PBL had been introduced in this program two yearspreviously. The tendency for psychiatric nursing not to be highly regarded by undergraduate nursing students had been central to development of this unit. It was therefore intended that the unit would not only equip students with the basic skills and knowledge of psychiatric nursing practice, but would increase the popularity of this area of practice as a future career option.
In addition to the use of PBL as an educational approach, the design of this particular undergraduate nursing program enhanced the conduct of this study. Years 2 and 3 of the program are both divided into two separate units of study of one semesterís duration. Students undertake both units during the year of study but are able to choose (depending on demand) whichunit they take in each semester. That is, both units run in each semester, with approximately half of the total cohort undertaking each of the units. This enabled a comparison of changes in attitudes to psychiatric nursing between students who had been exposed to the PBL psychiatric nursing unit, and students who had not. The results obtained could therefore be attributed to the unit of study as opposed to exposure to education at a more general level.
The experimental group for this study was the students undertaking the psychiatric nursing unit. The group of students of the same year level (Year 2) who undertook a unit of study examining the nursing of people with long-term illness, and aged care, acted as the control. As the students were able to select their unit of study for semester 1 a true experimental design was not possible.
The instrument used to pre and posttest students attitudes was based upon the questionnaire developed by Stevens & Dulhunty (1992;1994). Primarily the instrument required participants to rank the nursing practice areas in which they would most like to work after graduation in order of preference (1=most preferred; 9=least preferred). In addition, a number of open-ended questions were included in order that participants could provide further information regarding their choice of career preferences, in particular their most preferred and least preferred options, and their ranking of psychiatric nursing (where it is ranked other than first or last). Demographic details (age, sex and previous nursing experience) were also sought to enable the impact of these variables on psychiatric nursing as a career preference to be determined. Finally, participants were asked to include their date of birth and mother's maiden name, to enable the cross checking of responses between the pre- and post- test phases.
The study was conducted in one university located in Melbourne, Victoria. The first administration of the questionnaire to students took place on day one of the first year of study. The aim of the first phase of the study was to provide base-line data concerning the degree of popularity of psychiatric nursing as a career choice before nursing education had begun to influence attitudes. A questionnaire was distributed to all commencing Year 1 students during an introductory lecture. The students were informed that participation in the study was purely voluntary. They were asked if they agreed to participate to return the completed questionnaire at the end of the lecture. Completed questionnaires were received from approximately 70% (n=118) of commencing Year 1 undergraduate nursing students.
The second administration of the questionnaire took place during the last week of semester 1 of year 2 of the program. Due to the structure of the undergraduate nursing program, approximately half of the students had completed a unit of study in psychiatric nursing while the other half had completed a unit in long-term illness and aged care. A total of 114 completed questionnaires were returned during the second stage. During analysis of the data however, only 57 questionnaires could be cross-matched with questionnaires from phase 1, 30 from the experimental group and 27 from the control group. Statistical significance could nevertheless be achieved from the cross-matched questionnaires.
Data was analysed using SPSS for windows. The popularity of each of the career preferences was ascertained by calculating the mean, median and mode. The open-ended questions were examined and categorised according to commonalties. A code was assigned to each category to enable the calculation of frequencies to be conducted.
In demographic terms the overwhelming majority of students at the commencement of the undergraduate program is female, aged between 18 and20, with no prior nursing experience. There were only minimal differencesbetween the demographic profile of the control and the experimental groups.
One hundred percent of the control group was female, compared to 97% in the experimental group. The mean age of both groups was 21. Six percent of the experimental group had previous experience in nursing prior to commencing the course as compared to none in the control group. The pre-test ranking of psychiatric nursing between the two groups indicatedthat psychiatric nursing was slightly more popular in the experimental group where it was ranked at number 7 with a mean of 6.28, (median = 8, mode = 9) as opposed to a ranking of 8 by the control group with a mean of 7.19 (median = 8, mode = 9).
The findings of stage 1 of this study support the findings of previous research. Psychiatric nursing was ranked at number 8 from 9 possible career preferences. With a mean score of 6.95, median of 8 and mode of 9, only care of the elderly was ranked as less popular. The ranking of career preferences is demonstrated in Table 1.
Table 1: Career preferences of undergraduate nursing students, pre-test.
Analysis of the open-ended responses revealed the predominance of a negative view of psychiatric nursing. Participants from both the control and experimental groups described psychiatric nursing as depressing, frightening, emotionally draining, uninteresting, non-rewarding and an area of little status, as the following quotes demonstrate:
I'm not sure if I could handle psych. Patients. I'm a bit scared of that.
Psychiatric nursing has quite dark overtones. I imagine it to be quite threatening and sometimes frightening.
There's not a huge response from the patient to you as a nurse. No input from the patient in their care.
I have misconceptions due to stories I've heard and that accounts for everything.
In stage 2 a comparison between the pre- and post-test results for the experimental group suggests a positive relationship between completion of the psychiatric nursing program and the popularity of psychiatric nursing as a career choice. The ranking of psychiatric nursing increased from 7 to 3. Use of the Wilcoxon Matched-Pairs Signed Ranks test revealed a p-value of 0.00033 which confirmed the statistical significance of these changes. The pre- and post- test rankings of career preferences for the experimental group are represented in table 2.
Table 2 - Comparison of ranking of preferences for nursing career options by matched respondents within the experimental group between pre-test and post-test.
Analysis of the open-ended responses demonstrated a more positive view of psychiatric nursing was now characteristic of the experimental group. Fear and intimidation towards the mentally ill and the view of psychiatric nursing as uninteresting and unfulfilling were now extremely rare. Psychiatric nursing was now described as challenging, fulfilling, interesting and rewarding. Thirty seven percent of participants described either the theory of or clinical experience in, or both as the explanation for their change in attitude towards psychiatric nursing. The following quotes from students indicate the impact of the unit of study:
Surprisingly more interesting. The type of care is different with its counselling techniques and the therapeutic nurse ñ patient relationship.
Initially I would have put psych. last but after my clinicals it is more appealing.
I really enjoyed my clinical placement and Iíve become very interested in this [psych.] area.
I found psych. intriguing and interesting. It allowed me to use all skills learnt so far, e.g. psych. communication, holistic care.
In reviewing the results obtained from the control group a very different picture emerged. Psychiatric nursing increased slightly in popularity as demonstrated by a decrease in mean score from 7.19 to 6.81. However psychiatric nursing continued to be ranked at number 8 in the post-test scores. The Wilcoxon Matched-Pairs Signed Ranks test confirmed that the increase in popularity was not statistically significant. The pre- and post- test rankings of career preferences for the control group are represented in table 3.
Table 3: Comparison of ranking of preferences for nursing career options by matched respondents within the control group between pre-test and post-test.
An analysis of the open-ended responses reveals that there has been no substantial change in attitudes towards psychiatric nursing in the post-test phase. Fear of and apprehension towards the mentally ill is still prevalent, as is the image of psychiatric nursing as a boring, frustrating and unrewarding area of practice, as the following student quotes demonstrate:
I have little patience to re-explain things and I find it frustrating trying to communicate with them.
I think it would be very difficult because I've heard some psych. patients can be violent and unpredictable
There would be no normality about the wards.
There was an acknowledgement from some participants that their ranking of psychiatric nursing had been influenced by their lack of knowledge of this area, as stated:
I have no real interest as yet, my thoughts may change after completing the unit.
I don't know what it entails, therefore I ranked the areas that I know something about first.
The results of this study suggest that psychiatric nursing education has the potential to produce more positive attitudes towards the practice of psychiatric nursing. Although similar findings have resulted from previous research they are of greater statistical significance in the current study. In particular the work of Stevens and Dulhunty (1992;1994) indicated that undergraduate nursing education produced only a small change in the popularity of psychiatric nursing.
The use of a quasi-experimental design increases the probability that the results occurred as a result of the psychiatric nursing unit of study rather than by nursing education per se. The increase in popularity of psychiatric nursing from a ranking of 7th to a ranking of 3rd as compared to maintaining rank of 8th in the control group provides considerable support for a relationship between the study of psychiatric nursing and the development of more positive attitudes. Analysis of the open-ended responses of the participants further demonstrates a more positive view of the practice of psychiatric nursing and a decline in responses which indicated fear and stigma towards the mentally ill. The open-ended responses of the control group participants, on the other hand, continue to suggest that the negative images that were characteristics of phase 1 responses remain.
It would therefore seem reasonable to suggest that the degree andsignificance of the increase in popularity of psychiatric nursing in the current study is not the result of psychiatric nursing education alone. These findings support the evaluation of PBL (Happell 1998). As an educational method therefore, PBL has the potential not only to make the study of psychiatric nursing more relevant and interesting to students, it has the potential to create significant changes in attitudes.
More importantly, the results of this study provide a sense of hope topsychiatric nursing academics. While the battle to increasing the size orprofile of the psychiatric nursing component of undergraduate curricula mayat times seem insurmountable, and that there is no alternative to seeing psychiatric nursing continue as an unpopular career choice which struggles to attract sufficient graduates to meet staffing needs, the situation need not necessarily be so bleak. The educational approach can have an impact.
While the findings of this study support the value of PBL as an educational approach it is not intended to suggest that PBL omnipotent as the sole educational method to provide deliverance to psychiatric nursing. The aim of this paper is to promote further exploration and evaluation of educational methods which might enhance the profile of psychiatric nursing as a viable career choice for undergraduate nursing students.
As this study was conducted at one university only, it is not possible to generalize the results obtained in this study to a wider population of undergraduate nursing. The results may have been influenced by the timing of the study. The fact that the study was conducted immediately following the completion of the psychiatric nursing unit may have inflated the positive aspects of psychiatric nursing. There is therefore, a need for further research to ascertain the extent to which such positive attitudes are sustained over time.
As the aim of the research was not specifically to measure the effectiveness of PBL as a method, therefore the degree to which the results obtained can be attributed to the use of PBL as an educational method is limited. In order to be more confident about the impact of PBL it would be necessary to conduct a experimental study in which participants could be randomly assigned to either an experimental group in which PBL techniques are utilised, or a control group which utilises more traditional approaches to education.
The results of this study suggest that PBL as an educational method mayn contribute to the facilitation of more positive attitudes amongst undergraduate nursing students towards psychiatric nursing as a future career option. Despite the limitations of this study, the findings are of sufficient significance to warrant further research into the potential of educational approaches in psychiatric nursing. These results are promising not only for psychiatric nursing, but for all areas of nursing practice which do not tend to be viewed as favourable options by undergraduate nursing students.
The main intention of this paper was to initiate and contribute to furtherdiscussion in this area, to encourage psychiatric nursing academics to formally evaluate the teaching methods they use which they believe to be beneficial and to document and share such information with other psychiatric nursing academics.
Table 1. Ranking of nursing career options at the commencement of the course.
Table 2. Comparison of ranking of preferences for nursing career options by matched respondents within the experimental group between pre-test and post-test.
Table 3. Compariosn of ranking preferences for career options by matched respondents within the control group between pre-test and post-test.
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Last modified on: Tuesday, 24-May-2011 09:45:16 EST