Identification of Mental Health Problems in Students and Responsibilities In Nursing Education

Responsibilities In Nursing Education and Identification of Mental Health Problems in Students

Nursing Students with Mental Health Problems Identification, Faculty Responsibilities Related to Students with Mental Health Problems.

Nursing Students with Mental Health Problems Identification

    Even though nursing students may be considered to be at risk for developing mental health problems resulting from the high levels of stress that are generally reported among nursing students, little research has been conducted on interventions to alleviate mental health problems in nursing students. 

    What research exists has been primarily descriptive and has focused on behaviors, such as signs of anxiety, stress, and anger. Mental health issues include anxiety, depression, eating disorders, and obsessive compulsive behavior (Storrie, Ahern, & Tuckett, 2010). 

    Some nursing students may have mental health problems before enrolling in nursing school, which may have led them to be attracted to a “helping” profession. Students who experience mental health problems may need assistance in identifying and addressing these problems. 

    Undergraduate and graduate nursing students have many fears and worries about their ability to succeed in their program of studies. Test anxiety is a special form of anxiety often experienced by nursing students. With the advent of high-stakes testing, faculty should be on the alert to signs of extreme test anxiety (Røykenes, Smith, & Larsen, 2014). 

    Faculty who have close relationships with students may be the first to notice signs of stress and other mental health issues (Chernomas & Shapiro, 2013). Some behavioral indicators, either in the classroom or clinical setting, may include fatigue, poor concentration, change in outward appearance, frequent absenteeism, disruption of logical thought patterns, and a decrease in quality of work (Phimister, 2009). 

    Instituting interventions early can help ameliorate stress and anxiety experienced by nursing students. It is not necessarily easy to determine the sources of stress for nursing students because of the variety of research instruments used in studies. 

    Pulido Martos, Augusto Landa, and Lopez-Zafra (2012) concluded from their systematic review of the literature that, although specific conclusions were difficult to make, some sources of stress in nursing students were problems with studying, workload associated with nursing school, and fear of making mistakes while in the clinical setting. 

    They recommended that faculty examine how assessing students’ clinical skills can be conducted in such a way as to decrease stress experienced by students. Alzayyat and Al-Gamel (2014) also commented on how difficult it is to determine the sources of stress in nursing students in the clinical setting, because of lack of consistency with research instruments and inconsistent definitions of stress. 

    Stress and anxiety are prevalent in nursing students globally, especially fear associated with clinical practice, which can lead to depression. Chernomas and Shapiro (2013) measured student levels of depression, anxiety, and stress, and quality of life in 442 Canadian nursing students. Students reported high-normal ranges of depression, anxiety, and stress. 

    Although the majority (84%) rated their quality of life as good or very good, 40% reported sleep disturbances and 41% reported little time for leisure activities. Qualitative comments reinforced that fears related to clinical practice contributed to stress and anxiety. Chernomas and Shapiro recommended that faculty should attend faculty development workshops to learn how to ameliorate students’ perceived stress, anxiety, and depression. 

    Moridi, Khaledi, and Valiee (2014) confirmed that clinical practice was a major source of stress for 230 nursing students in Kurdistan. Shaban, Khater, and Akhu-Zaheya (2012) showed that avoidance coping behaviors in Jordanian nursing students in clinical practice increased stress, whereas problem-solving coping behaviors decreased stress. 

    In their study of depression in nursing students Xu et al. (2014) administered a depression scale to 729 Chinese nursing students. They found a positive relationship between lower depression and better career prospects, academic performance, and quality of interpersonal relationships. 

    Recommendations included developing school- and family-based programs to prevent depression. Cha and Sok (2013) found that anger expression, depression, and self-esteem were related in a sample of 320 Korean students. They recommended that students be taught how to control anger as a way to enhance self-esteem and decrease depression. 

    A study of 335 graduate and undergraduate Thai nursing students revealed that high stress was correlated with poor health and higher psychological distress (Klainin-Yobus et al., 2014). They found, however, that stress was more related to psychological distress than poor physical health. 

    A study of 123 nursing students in Cyprus showed that strength of religious and spiritual beliefs was related to less depression and stress and more self-esteem (Papazisis, Nicolaou, Tsiga, Christoforou, & Sapountzi-Krepia, 2014). 

    The aforementioned global studies of factors that contribute to mental health issues in nursing students, certainly confirm the assumption of Papazisis et al. (2012) that nursing faculty cannot draw strong conclusions from this body of descriptive research because few studies were multisite and a variety of data collection instruments were used. 

    Furthermore, these recent studies occurred outside the United States and might not be fully applicable to students in the United States. Nevertheless, the commonality in the findings does lend credence to some generalizability. 

    Stress in clinical practice has also been shown to be related to organizational characteristics in clinical agencies. Blomberg et al. (2014) examined stress levels in 74 Swedish students from three different universities in their final course of study. As with other studies, a majority of the students experienced stress, especially students who were placed in hospitals for their clinical experiences. 

    Some of the students took a National Clinical Final Examination (NCFE) during the clinical placement. Results demonstrated that students placed in hospitals that were crowded, had multiple supervisors rather than one supervisor or preceptor, and took the NCFE during their placements had higher levels of stress. Such findings could have implications for how clinical experiences are implemented. 

    The investigators recommended that experimental studies be conducted to determine which models of clinical supervision might reduce stress. Most studies of mental health issues have been descriptive. However, several studies have investigated the effect of interventions on stress and anxiety reduction. 

    Kang, Choi, and Ryu (2009) tested mindfulness meditation as a strategy to decrease stress, anxiety, and depression. Forty-one nursing students were randomly assigned to experimental and control groups. The experimental group participated in 90- to 120-minute sessions for 8 weeks. 

    Before randomization, both groups attended a lecture about stress management. Following the intervention, students in the experimental group had decreased anxiety and stress. However, the amount of depression was not significantly different between the two groups.

    Van der Reit, Rossiter, Kirby, Dluzewska, and Harmon (2015) conducted a descriptive, qualitative pilot study with 14 first-year undergraduate and midwifery students designed to evaluate the effects of a 7-week stress management and mindfulness program. 

    From the themes identified, van der Riet and colleagues determined that the program helped students sleep better, have fewer negative thoughts, and promoted better patterns of concentration. However, challenges were encountered during the program, primarily students’ inability to attend all sessions because of class commitments. 

    While specific training can help students learn to control their anxiety, the role of faculty and peer mentoring cannot be overlooked when dealing with anxiety. Appropriate use of humor can also lessen anxiety, help increase self-esteem, and contribute to an overall positive learning environment (Moscaritolo, 2009). 

    A more positive learning environment may lead to better student learning outcomes. Another strategy that has been tested to decrease stress and increase academic performance is the use of a “home” hospital program (Yucha, Kowalski, & Cross, 2009). The home hospital program involved keeping nursing students, as much as possible, at the same clinical agency throughout their program of study. 

    Nurses in the hospitals served as the clinical instructors. The program was predicated on the fact that familiarity with the clinical agency can decrease stress and, as a side benefit, be used as a recruiting tool for the agencies involved. Students participating in the program reported less anxiety than those students who did not participate in the “home” hospital model. 

    While some interventions have shown promise in helping students deal with stress and anxiety, students’ willingness to participate in interventions may be influenced by their attitudes towards prevalence of stress in themselves and others, and their willingness to seek help. 

    Galbraith, Brown, and Clifton (2014) gathered data from 219 British nursing students regarding willingness to seek help for stress-related conditions. Descriptive analysis of the data demonstrated that 74.9% of the students had experienced stress. Most students (87.2%) would disclose their stress to family and friends. 

    Few would disclose to colleagues or professional institutions because they believed families could best offer advice. Only 11.4% would seek professional help. Students revealed that they would not lose confidence in colleagues who had stress. Another interesting finding was that students had generally recognized existing high levels of stress in the nursing profession. 

    Given these findings, if research-based interventions were offered on a regular basis to nursing students, it’s unclear whether students would even avail themselves of the opportunity to engage in stress and anxiety reduction programs.

Faculty Responsibilities Related to Students with Mental Health Problems

    Mental health issues range from anxiety, including test anxiety, and stress to severe depression and other mental illnesses. The process used to assist students with suspected mental health problems is similar to the approach used with any student whose academic progress is jeopardized by unsatisfactory performance. 

    First, the ADA/ADAAA prohibits discrimination against individuals who are mentally impaired. Second, all actions taken by faculty must be congruent with existing institutional policies and afford students the due process that is their right. When mental health issues interfere with student behavior, faculty must deal with this behavior in a manner consistent with institutional policy. 

    According to Cleary, Horsfall, Baines, and Happell (2012), policies must include confronting the student with evidence of problematic behavior and the faculty member needs to facilitate reduction of the problematic behavior before action is taken. 

    Students should be made clearly aware of the behavior adversely affecting their academic performance and what they need to do to correct this behavior. A learning contract may be used in this instance to indicate what the student needs to do to improve the behavior and the time frame in which this must be accomplished. 

    Many campuses have student codes of conduct to guide policy development. Policies, according to Cleary et al. (2012), should delineate procedures for assessing, documenting, reporting, intervening, and referring students for treatment. Many university campuses offer this service to students free or for a reduced fee.

    If, despite these interventions, the behavior does not improve and the student is unable to perform effectively or patient safety is compromised, administrative withdrawal or dismissal from the program may be necessary. As always, the student who is administratively withdrawn or dismissed has the right to pursue the grievance and appeal process in place within the institution.

    Mental health issues may display themselves in the form of student incivility in the classroom and ultimately in anger within the student faculty relationship and perhaps lead to violent episodes (Clark, 2009). However, mental health issues cannot be used to justify incivility. 

    Behaviors indicative of incivility in students include making sarcastic remarks, sleeping in class, distracting others with side conversations, using cell phones in class, arriving late and leaving early, and making demands of faculty (Clark, Farnsworth, & Landrum, 2009). Clark (2009) has suggested that to deal with incivility, faculty should recognize the risk factors such as competitive academic environments and clinical placements. 

    Faculty can then design strategies to ameliorate the stress and anxiety that results from these factors. Clark (2009) also recommended that faculty test the strategies to determine their efficacy. See Chapter 14 for a more in-depth discussion of student and faculty incivility.