UBC Undergraduate Research

Exploring Sustainability: Supporting Mental Health of Health Care Students Barbosa, Kristel Vanessa Jul 31, 2009

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UNIVERSITY OF BRITISH COLUMBIA DIRECTED STUDY PROJECT (NURS 410F)  Exploring Sustainability: Supporting Mental Health of Health Care Students  Submitted to: Patricia Rodney Professor, RN, MSN, PhD UBC School of Nursing Annalee Yassi Professor, B.Sc., MD, MSc UBC School of Population and Public Health  By: Kristel Vanessa Barbosa Student Nurse (4th year) UBC School of Nursing  July 2009  Table of Contents I. Introduction............................................................................................................................. 3 II. History..................................................................................................................................... 3 III. Present................................................................................................................................. 4 1. Student Nurses .................................................................................................................... 4 2. Other Health Care Students ................................................................................................ 5 3. Need for Better Sustainability of Health Care Students’ Mental Health ............................ 6 IV. Future .................................................................................................................................. 7 1. Supportive Academic and Practice Environments.............................................................. 8 a) Stress and Anxiety Management Programs .................................................................... 8 i) Anxiety Reduction Programs...................................................................................... 8 ii) Mindfulness-Based Stress Reduction Programs (MBSP)........................................... 9 b) Peer Mentors ................................................................................................................... 9 c) Safety Nets ...................................................................................................................... 9 i) Mental Health Awareness ........................................................................................... 9 ii) Counselors................................................................................................................... 9 2. Ongoing Research............................................................................................................. 10 a) Stigma ........................................................................................................................... 10 b) Academic and Practical Pressures ................................................................................ 11 c) Supports for Faculty in Health Disciplines................................................................... 11 3. Policy Development.......................................................................................................... 11 V. Conclusions........................................................................................................................... 12 VI. References......................................................................................................................... 13  2  I.  Introduction Students in health disciplines are exposed to psychosocial risks related to clinical work  and academia. Such occupational hazards have been identified as major challenges for the health and safety of health care students. This paper covers historical aspects of the occupational mental health of student nurses and explores the current health status of health care students. Moreover, the study provides basic recommendations to promote research, policy and practice for the reduction of occupational psychosocial hazards within the health care student population II.  History History helps us learn from the past, inform today’s discussion, and connect bridges for  future directions (Lamb, 2004). To observe the evolution of occupational mental health in the student population, it is necessary to look into the historical aspects of the health care professions’ participation in their own occupational health. Thus, this section will analyze the history of mental health promotion in the nursing profession. Nursing history appears to have been affected by hierarchies of gender, ideologies of knowledge, and dominant institutional realities (Dick & Cragg, 2006). In the early days of nursing, the characteristics of what was considered a “good” nurse contained the concepts of obedience, acceptance of authority, unselfishness and altruism (Lamb, 2004). Moreover, nursing students were expected to work long hours (12-hour shifts) with only one-half day off per week (Dick & Cragg, 2006). Even though no formal information about the mental health of student nurses in these early days of nursing was found during the literature review of this study, the occupational mental health of student nurses may have been negatively affected by the profession’s historical self-sacrificing nature. Consequently, mental health promotion and support strategies were likely absent during the past generations of nursing schools’ policies. It is there-  3  fore not unreasonable to hypothesize that nursing students used to be exposed to high levels of stress with no or only minimal supports to maintain their sustainable mental health. III.  Present “[Sustainability is to] meet the needs of the present world population without causing  adverse effects on health […] hence without compromising the ability of future generations to meet their needs” (WHO, 2009). Throughout the literature it is repeatedly noticeable that health care students are exposed to psychosocial hazards with the potential of serious harm - including suicide (Compton, Carrera, & Frank, 2008). To further illustrate the health status of these students, relevant literature will be used to explore these students’ situations. 1.  Student Nurses Student nurses are exposed to mainstream stresses of academic students: long hours of  study, academic pressures, and difficult learning materials (Sharif & Armitage, 2004). In addition, nursing students may feel the stress brought by the pressures of clinical practice (Kanji, White & Edzard, 2004). Today, despite the enhancement in nursing education, there appears to be a pattern among student nurses that involves periods of stress and dissatisfaction. In fact, it is not uncommon for nursing students to feel anxiety during their education. This phenomenon of anxiety and stress seems to be a common occurrence for the majority of student nurses (Moscaritolo, 2009). Furthermore, it is often encountered that these students suffer from higher levels of anxiety than fellow university and college peers. It is important to note the impact of stress and anxiety levels because they can be very taxing to student nurses’ health as they “impede concentration, memory, and problem solving ability” (Beddoe & Murphy, 2004).  4  In the past decade there have been several qualitative studies that report factors contributing to the anxiety and stress levels felt by undergraduate student nurses. According to this literature, nursing students have reported that the most common factors provoking anxiety and stress were related to the fear of making clinical mistakes, performing clinical skills, performance evaluation and neglected support by nursing personnel (Locken & Norberg, 2005). Nursing students spend the majority of their learning time inside the clinical area; clinical practice is usually three times greater than the theoretical classroom time (Locken & Norberg, 2005). Therefore, in order to promote a supportive environment where students can practice their skills and experience success, it is vital to pay closer attention to the anxiety and stress levels of student nurses during clinical rotations (Moscaritolo, 2009). 2.  Other Health Care Students Nursing students appear to not be alone in experiencing psychological imbalances within  the health care student population. A great number of medical students also face stressors that may eventually lead to emotional maladjustments. Such detrimental factors involve: “relocation away from family and other social supports, mounting financial debts, sleep deprivation, encounter with human suffering and mortality, changes in health habits, and emotional and academic adjustments” (Compton et al, 2008, p. 891). In addition, the literature illustrates the correlation between medical students’ poor mental health and low career satisfaction with belittlement or harassment during their clinical training (Frank, Carrera, Stratton, Bickel & Nora, 2006). This harassment and belittlement towards medical students appears to be generally caused by clinical professors and residents. The data suggests that abusive behaviour from those in power contributes to students’ poor mental health (Frank et al, 2006).  5  Additionally, medical students may experience higher rates of depression when compared to the general population; the likelihood of them being treated medically, however, is not proportionate (Compton et al., 2008). The progression of depression among medical students may become even greater as they proceed in their studies. Besides being harmful to the personal lives of medical students, depression can also negatively impact their academic performance and even patient care (Compton et al., 2008). Alarmingly, medical students suffering from depression may not be treated even when its severity may reach levels of suicidal ideations (Compton, et al., 2008). Comptom et al. (2008) describe that students with suicidal ideations are more likely to consume tobacco, alcohol, and illicit drugs, as well as engaging in other risky behaviours. Suicidal ideations are psychiatric disorders that pose a special risk to medical students as statistically their age category is known for a high number of completed suicides, when compared to the general population. Some of the predictor factors for suicidal ideations compromise stress, anxiety, depression, and students’ perceptions of lack of control and missing support from their schools (Compton et al., 2008). Despite the severity of poor mental health, however, medical students may not seek appropriate help, as it may be seen as personal weakness and poor knowledge of existing mental health services (Compton at al, 2008). Unquestionably, these hindering factors negatively affect the sustainable health of medical students. 3.  Need for Better Sustainability of Health Care Students’ Mental Health When exploring the literature, health care students appear to be experiencing some of the  general population’s major contemporary challenges of occupational health and safety: psychosocial risks concerned with aspects of the design and management of work and its social and organizational contexts (WHO). Consequently, there ought to be prevention measurements of  6  occupational diseases in order to minimize psychosocial hazards that may cause unnecessary loss of human resources (WHO). IV.  Future If health care students were to effectively tackle occupational psychosocial hazards, it is  necessary to provide appropriate resources to help them sustain their optimum mental health. In order to provide a comprehensive approach to sustainable occupational mental health, it is essential to acknowledge the relevant sectors involved: prevention, treatment, care, rehabilitation and research (WHO). The Alma Ata Declaration emphasizes the need to organize primary health care services, both preventive and curative, as close as possible to where people work (WHO). The declaration states that high priority should be given to the people most in need, including working populations at high risk. As health care students appear to be in great need for more sustainable approaches to optimize their mental health, more accessible services ought to be offered to them. To effectively address the psychosocial hazards in the health care student population, it is furthermore crucial to identify the health determinants which are most connected to the root causes of common psychiatric disorders among health care students. As the information discussed in the “present” part of the paper suggests and based on the social determinants of health (O’Hara, 2005), the mental health of students may be the most impacted by social support networks, education, social environments, personal health practices and coping skills, and health services. Through secondary research and informal interviews with experienced health care professionals, relevant information was gathered to analyze the current recommendations to promote and support students’ sustainable mental health. The recommendations are grouped into three  7  categories: supportive academic and practice environments, ongoing research, and policy development. The categories address relevant health determinants at different stages of care for health care students. 1.  Supportive Academic and Practice Environments Health care students spend numerous hours of their learning in the clinical setting, thus, it  is vital for schools in the health disciplines to be aware of their students’ mental health. If schools were to be active key players in the promotion and maintenance of supportive practical learning environments, the students’ experiences with success could be better supported (Moscaritolo, 2009). Despite the busy schedule of schools in health disciplines, the inclusion of interventions to sustain the mental health of students is therefore necessary to provide patients with competent and confident future professionals. For the purpose of this study, basic directions for interventions were clustered into stress and anxiety management programs, peer mentors, and safety nets. a)  Stress and Anxiety Management Programs i) Anxiety Reduction Programs In order to help students cope effectively with tension and feelings of inadequacy, coun-  seling is essential. According to Sharif and Armitage (2004), the component of psychological counseling may lead to reduced anxiety and increased self-esteem. Moreover, anxiety-reduction programs have shown to significantly decrease depression (Godbey & Courage, 1994). Therefore, psychological counseling may help students feel less anxious and more confident in their academic and clinical performance. Consequently, this intervention may accommodate better academic and clinical performance of health care students.  8  ii) Mindfulness-Based Stress Reduction Programs (MBSP) According to the literature, mindfulness training is an effective intervention to decrease anxiety among undergraduate health care students (Moscaritolo, 2009). If MBSPs were to be offered to students through new or current elective courses, there could thus be an improved level of mental wellness within the health care student population. b)  Peer Mentors According to Moscaritolo (2009), when health care faculty offer peer-help to students  who have been identified as experiencing anxiety, the intervention appears to help protect and promote the mental health of these students (Moscaritolo, 2009). Therefore, peer mentoring programs may be included as an intervention option when health care students are experiencing high levels of anxiety. c)  Safety Nets i) Mental Health Awareness Students should be aware of the potential occupational mental health issues that are in-  volved with health care professions: “It is necessary to learn to swim; you cannot go blindly into the job” (Straight, 2009). It is also necessary that health care students are educated to self-care from the beginning of their professional development (Straight, 2009). For example, students may be taught on the importance of finding outlets, such as support groups, to help them deal with stress and anxiety in an effective and healthy manner. ii) Counselors If health care students express having psychological issues, students ought to be referred to counselors for specialized professional and non-judgmental support. In the best case scenario, the recommended counselors should be aware of the culture of the health care student popula9  tion, so that the counselors gain a reputation for credibility and trust-worthiness among students (Logie, 2009). 2.  Ongoing Research While the literature describes health inequities faced by health care students, for-  mal information about what may work to reduce those inequities is, so far, very limited. The current literature needs to be further expanded in order to create comprehensive interventions that help maintain the health of students. The continuation of research in this area may strengthen the knowledge base on and the monitoring of health inequities encountered by health care students. Research development may not only have the function to help improve these individuals’ health status, but it may also facilitate the formation of more confident and competent workers. Based on current literature and on input of health care professionals, there were three specific research areas identified as critical for the knowledge development in the area of mental health sustainability in the health care student population: stigma, academic and practical pressures, and supports for faculty in health disciplines. a)  Stigma The stigma associated with mental illnesses act as a great barrier for students to access  mental health services, even when desperately in need of such (Compton et al., 2008). The stigma linked with accessing mental health supports may bring an overwhelming sense of personal failure, which in turn may be negatively judged from the outside as weakness (Groening, 2009). The negative social implications brought by stigma can also affect students’ decisions to temporarily withdraw from their study programs to attend mental health services when experiencing psychiatric disorders. Thus, further research is needed to understand how to decrease the  10  stigma associated with mental illnesses among health care students and to analyze how to make mental health services socially accessible to these students. b)  Academic and Practical Pressures Students in health care fields are exposed to a demanding environment requiring numer-  ous hours of learning effort. Health care students run the risk of being in cycles where they neglect their own mental health, because they may not have sufficient time to care for themselves or to access appropriate resources when in need (Esson, 2009). Therefore, more research is needed to see how time pressures may impact the sustainable mental health of students and what supports may be provided to decrease the impacts brought by time pressures. c)  Supports for Faculty in Health Disciplines At present, literature describing interventions to help sustain the mental health of faculty  in the health disciplines is scarce. Thus, relevant studies in the area may provide faculty with knowledge to be better equipped to assist students experiencing mental illnesses and to do so at a more competent level (Leung, 2009). 3.  Policy Development In order to effectively support the mental health of students, it is necessary to take steps  towards the design, development, and operation of projects that are student-centred. Policy efforts need to provide practical and innovative measures to tackle health inequities faced by health care students. To enable policies to provide sustainable strategies to effectively reduce health inequities, further research development and increased cooperation between different sections of society at the global, federal, provincial, and local level are essential. An active dialogue between stakeholders would allow for mutual learning and sharing of information. The communication among stakeholders may also promote best practice methods to 11  be translated from theory to concrete plans, and thus create comprehensive risk reduction interventions. Once implementation has taken place, evaluations would enhance the sustainability of such policies. Expectantly, the outcomes of measures to tackle students’ mental health issues may improve the affected individuals’ quality of life, and improve their performance and productivity at work. V.  Conclusions The occupational mental health of health care students has historically been disregarded  to a great extent. The current literature reveals that a substantial proportion of health care students is likely to experience psychological illnesses, especially in the practical setting. This issue appears to impact students’ clinical competence, career satisfaction and personal lives. As the mental health of students is closely connected to the occupational environment, it is necessary to warrant further attention to their occupational mental health. Further research is necessary to clarify how the occupational mental health of students can be best promoted and supported during academic and practical education. Moreover, research is required to explore how to provide students with socially accessible mental health services. Additionally, to improve the students’ professional capacity and well-being, it is necessary to create supportive academic and practice environments, to maintain ongoing research and to develop policies that support students’ mental health. A healthy, productive and wellmotivated population of health care students may improve the quality and safety of patient care. Since today’s health care students constitute tomorrow’s health care force, it is necessary for society to pay considerable attention to these individuals’ mental health.  12  VI.  References  Beddoe, A.E., & Murphy, S. O. (2004). Does mindfulness decrease stress and foster empathy among nursing students? Journal of Nursing Education, 43, 605-312. Compton, M., Carrera, J. & Frank, E. (2008). Stress and Depressive Symptoms/Dysphoria Among US Medical Students: Results From a Large, Nationally Representative Survey. The Journal of Nervous and Mental Disease, 196(12), 891-7. Dick, D.D., & Cragg, B. (2006). Undergraduate edctoiin: Development and politics. In M. McIntrye, E. Thomlinson & C. Mcdonald (Ed.), Realities of Canadian nursing (2nd ed., Ch. 11). Philadelphia: Lipincott. Esson, L. (2009). Informal interview conducted by writer (re: sustainability of students’ mental health). Vancouver, May 15, 2009. Frank, E., Carrera J., Stratton, T., Bickel, J., & Nora, L.M. (2006). Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal sutvery. British Medical Journal, 333(3), 682. Godbey, K.L. & Courage M.M. (1994). Stress-management program: intervention in nursing student performance anxiety. Archives of Psychiatric Nursing, 8(3), 190-9. Groening, M. (2009). Informal interview conducted by writer (re: sustainability of students’ mental health). Vancouver, May 15, 2009. Kanji, N., White, A., Ernst, E. (2004). The effect of psychological and educational counselling in reducing anxiety in nursing students. Journal of Psychiatric & Mental Health Nursing, 11(4), 386-92.  13  Lamb, M. (2004). An Historical Perspective on Nursing and Nursing Ethics. In J. L. Storch, P. Rodney & R. Starzomski (Ed.), Towards a Moral Horizon: Nursing Ethics for Leadership and Practice (1st ed., Ch. 2). Ontario, Toronto: Pearson Education Canada Inc. Leung, L. (2009). Informal interview conducted by writer (re: sustainability of students’ mental health). Vancouver, May 15, 2009. Locken, T., & Norberg, H. (2005). Reduced anxiety improves learning ability of nursing students through utilization of mentoring triads. In Moscaritolo, L.M. (2009). The effect of psychological and educational counselling in reducing anxiety in nursing students. Journal of Nursing Education, 48(1), 17-23. Logie, A. (2009). Informal interview conducted by writer (re: sustainability of students’ mental health). Vancouver, April 15, 2009. Moscaritolo, L.M. (2009). The effect of psychological and educational counselling in reducing anxiety in nursing students. Journal of Nursing Education, 48(1), 17-23. O'Hara, P. (2005). Creating Social and Health Equity: Adopting an Alberta Social Determinants of  Health  Framework.  Retrieved  February  18,  2009  from  http://www.who.int/social_determinants/resources/paper_ca.pdf Sharif F; Armitage P (2000). The effect of psychological and educational counselling in reducing anxiety in nursing students. Journal of Psychiatric & Mental Health Nursing, 11(4), 38692. Straight, H. (2009). Informal interview conducted by writer (re: sustainability of students’ mental health). Vancouver, April 15, 2009. World Health Organization (WHO) (2009). Occupational Health. Retrieved May 5, 2009 from http://www.who.int/occupational_health/en/  14  15  

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