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Effectiveness of Continuing Nursing Education Program in Child Psychiatry

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PROBLEM: Program evaluation of the effectiveness of two continuing nursing education programs (CNE) in child psychiatry in India.METHODS: Pre- and postevaluation of a total of 51 nurses attending a 10-day CNE program, using a 30-item (six-domain)
    JCAPN Volume 19, Number 1, February, 200621   Journal of Child and Adolescent Psychiatric Nursing, Volume 19,Number 1, pp. 21–28  .  BlackwellPublishing,Ltd.Oxford,UK JCAPJournalofChildandAdolescentPsychiatricNursing1073-6077©2006byNursecom,Inc.191  ORIGINALARTICLE   EffectivenessofContinuingNursingEducationPrograminChildPsychiatry  XX  Effectiveness of Continuing Nursing Education Program in Child Psychiatry  Nirmalya Chakraborty, RN, DPN, Baxi Neeraj Prasad Sinha, MBBS (Hons), DPM, MD, DNB, S. Haque Nizamie, DPM, MD, Vinod Kumar Sinha, DPM, MD, Sayeed Akhtar, MD, DNB,  Jyoti Beck, RNRM, DNEA, DPN, and B. Binha, RNRM, DNE, DPN  PROBLEM:  Program evaluation of the effectiveness of two continuing nursing education programs (CNE) in child psychiatry in India.  METHODS:  Pre- and postevaluation of a total of 51 nurses attending a 10-day CNE program, using a 30-item (six-domain) questionnaire according to CNE topics in child psychiatry.  FINDINGS:  The CNE program resulted in significant increase in the total scores as well as scores in several sub-domains in the field of child psychiatry.  CONCLUSIONS:   In a country that does not offer degree programs that integrate psychiatric nursing into the curriculum, CNE programs are an important educational option for nurses. The CNE program offered in this study, comprising lectures, discussion, interactive sessions, and case demonstrations totaling 60 hr across 10 days,  was effective in improving the level of knowledge of nurses. It was equally beneficial for senior as  well as less experienced nurses.  Search terms:  Child psychiatry, nursing, continuing education, efficacy of psychiatric nursing education in India Nirmalya Chakraborty is a staff nurse, Baxi Sinha is senior resident, S. Haque Nizamie is the Director and professor of Psychiatry, Vinod Kumar Sinha is associate professor of psychiatry and in-charge, Sayeed Akhtar is consultant psychiatrist, and Jyoti Beck is the assistant nursing superintendent at the Central Institute of Psychiatry,  Jharkrand, India.   P  sychiatric illnesses have been a neglected area inthe medical field in India and child psychiatry evenmore so. However, it is very important to be aware of the childhood psychiatric problems in order to iden-tify them early, so that suitable interventions can bestarted in the early stage of the disorder (Indian Coun-cil of Medical Research, 2001). It is estimated that thereare about 350 million children and adolescents inIndia, which comprise about one-third of the entirepopulation (Census of India, 2001), 7–30% of thesehaving various childhood psychiatric disorders(Malhotra, 2002).In India, child mental health services were startedabout four decades ago (Shah & Sheth, 1998). TheNational Policy for Children (1974) was the first long-term step in India for the preventive and promotiveaspects of child health care, especially for preschoolchildren, and for the education for other groups of children. National children’s boards were establishedat the center and state levels for planning, review,and coordination of all essential services. IntegratedEducation for Disabled Children (1974) was started tointegrate the physically and mentally handicappedchildren in the community and to provide educationalopportunities for disabled children in school. TheNational Mental Health Program for India (1982) aimedto provide treatment, rehabilitation, and preventionof illness for adults and children. The school mentalhealth programs (SMH) in India were initiated prima-rily by nongovernment organizations, with technicalsupport from premier postgraduate training institutes(Kapur, 1997). Structured SMH programs are also beingcarried out through tertiary psychiatry institutions   22JCAPN Volume 19, Number 1, February, 2006  Effectiveness of Continuing Nursing Education Program in Child Psychiatry  (Sinha, Thomas, & Thakur, 2003). The National Policyon Education (1986) was declared for early childhoodcare and education with a comprehensive framework.The policy aimed at free as well as compulsory educa-tion up to 14 years of age.The magnitude of the problem of childhood psychi-atric disorders in the developing countries likeIndia can be gauged by the results of a multicentricWorld Health Organization (WHO)-sponsored studyof childhood mental disorders in primary health care infour developing countries, where Giel et al. (1981) havereported that 12–29% of children attending a primaryhealthcare facility in Columbia, India, Senegal, andSudan had identifiable psychiatric disorders. It is evenmore alarming that out of these, 80–90% were consist-ently missed, or in other words, they did not receiveadequate psychiatric help because of lack of recognitionand knowledge. Various studies in the epidemiologyof childhood psychiatric disorders in India also pointtoward a similar direction. The prevalence of psychiatricdisorders in children is 33.7%, whereas the commondisorders seen were: enuresis (14.3%), conduct disorder(11.1%), mental retardation (2.9%), and hyperkineticsyndrome (1.7%) (Deivasigamani, 1990). Based on epi-demiological studies carried out in different parts of India, the prevalence of various psychiatric disordersamong children is as follows: learning or scholasticproblems, 10% (Shenoy & Kapoor, 1996); attentiondeficit hyperactivity disorder (ADHD), 3% (Mishra &Sinha, 2001); and depressive disorders, 3.13% (Sarkar& Sinha, 2004).The first child guidance clinic in India was startedin 1937, and 120 child guidance clinics are functionalin India presently (Kapur, 1995). It has been observedthat overall, there is a lack of well-qualified, trainedstaff in India to cater to the needs of children sufferingfrom various childhood psychiatric disorders (Shah &Sheth, 1998). Overall, in India there remains a shortageof trained psychiatric personnel, especially nurses.Regarding children suffering from psychiatric illnesses,nursing care is quite demanding and requires specializedknowledge. The special role of professional nurses inchild psychiatry has also been acknowledged byothers (Walshe-Brennan, 1997). However, specializedtraining for nurses in child psychiatry as structuredregular courses is nonexistent.  Psychiatric nursing is not a very sought-after career among nurses in India and many nurses harbor a negative attitude toward psychiatry. Special short-term programs are sometimes used to try to bring about a more positive outlook about the field.  A CNE program on child psychiatry is important inthis scenario in our country because it has been docu-mented in several studies that many children withpsychiatric problems first consult the general hospitals,where unfortunately many of them are often missed(Shah & Sheth, 1998), which is chiefly because of poorknowledge about the subject matter.Moreover, psychiatric nursing is not a very sought-after career among nurses in India and many nursesharbor a negative attitude toward psychiatry. Specialshort-term programs are sometimes used to try to bring about a more positive outlook about the field.It has been shown that a positive change in attitudestoward psychiatric nursing can be brought about bypsychiatric nursing education programs (Louise &Brenda, 1998; Bendtsen & Akerlind, 1999). Ongoingeducation programs and ward-based support have been shown to be necessary to ensure that the knowl-edge gained continues to be applied in the practicesetting (Allison, 1995), whereas continuing professionaleducation programs can positively influence nursing    JCAPN Volume 19, Number 1, February, 200623  practice and the standard of care delivered (Wood,1998). This view is supported by the literature withmany references being made to the importance andvalue of continuing education for nurses (Jarvis, 1987;Brown, 1988; Nugent, 1990; Thurston, 1992).The current study was undertaken with the aim toevaluate the short-term effectiveness of CNE programsthat aim to equip nursing personnel with knowledgeand skills to identify abnormal psychological, beha-vioral, cognitive and affective responses in children,and to provide baseline information for the nurses toplan nursing interventions for children sufferingfrom various mental illnesses.  MethodParticipants and Setting  The present study was conducted at the CentralInstitute of Psychiatry (CIP), Ranchi, India. The CIP is aWHO-accredited psychiatry center and is the tertiaryreferral center for the eastern part of the country, hav-ing 673 inpatient beds and a separate child psychiatryunit, which was the first of such in the country, andhas been operational since 1951. It is a postgraduatepsychiatry teaching institute, conducting regular coursesin Diploma in Psychiatric Nursing (DPN) for nurses,Diploma in Psychological Medicine (DPM) and MD inPsychiatry for doctors, M.Phil in Clinical Psychologyand PhD for psychologists, and M.Phil for psychiatricsocial workers.The present study was carried out during two10-day CNE programs from August 20, 2002, to August29, 2002, and from September 2, 2003, to September 9,2003. Each CNE program comprised 6 hr teaching perday over 10 days, totaling 60 hr. Subjects included atotal of 51 trained nurses from different hospitals whoregistered in either of the CNE programs and gaveinformed consent for the study (27 subjects in the firstand 24 in the second, none of them attended both).The basic qualification for each nurse (whoattended the CNE) was 3 years of general nursingtraining after a minimum of 10 years of formal schooleducation (for registered nurse [RN]). Some participantsalso had higher educational qualifications (detailed inTable 1). The program was designed for registerednurses working in different state-owned and privatehospitals of this region.The subject matter was finalized after extensivediscussions with faculty members. It included an over-view of child psychiatry; normal development (physical,cognitive, social, and moral); assessment (history-takingand interview); learning disorders; pervasive develop-mental disorders; attachment and elimination disorders;ADHD; schizophrenia and mood disorders; anxiety andneurotic disorders; eating disorders; conduct disorder; Table 1.Sociodemographic Variables   Variables ( n  = 51)Mean ±±±±  SD/percentage ( n ) Age34.69 ( ± 8.09) years (mean [ ± SD])Sex3.9% ( n  = 2) males; 96.1% ( n  = 49) femalesMarital status67.3% ( n  = 35) marriedGeneral school education (prior to joining 2% ( n  = 12) class 10; 92.2% ( n  = 30) class 12nursing training)5.9% ( n  = 9) graduate (15 years formal education)Nursing training96.1% ( n  = 49) diploma in nursing (RN)3.9% ( n  = 2) B.Sc. in NursingWork experience–general hospital setup3.55 ( ± 6.40) years (mean [ ± SD])Work experience–psychiatry hospital setup6.49 ( ± 7.50) years (mean [ ± SD])   24JCAPN Volume 19, Number 1, February, 2006  Effectiveness of Continuing Nursing Education Program in Child Psychiatry  child abuse; epilepsy in children; IQ assessment; child-hood mental disability/mental retardation; nursing careof children with emotional and behavioral problems;mental health and mental hygiene; and child mentalhealth policy in India.Teaching comprised classroom lectures, case dem-onstrations, ward rounds, group work, discussion withaudiovisual aids, individual assigned work, case confer-ence, and a quiz competition. Resource persons includednursing tutors (faculty members for postgraduatediploma course in psychiatric nursing at our institute),clinical psychologists, psychiatric social workers, andpsychiatrists. The same teaching materials and formatwere used for both the CNE programs. Financial grantsfor the programs were provided by the India Ministryof Health and Family Welfare in New Delhi. No feewas charged to the participants, who were providedwith government-approved allowances and otherfacilities for attending the same.  Tools Used for Program Evaluation  Program evaluation was planned at the time of designing the course content. A total of 30 questionswere drafted, covering the CNE topics by the nursingtutors and experienced psychiatrists, in consultationwith the resource persons for the program. The ques-tions were broadly divided into the following sixmajor domains: domain A, developmental milestones;domain B, mental retardation and learning disorders;domain C, psychopharmacology and management;domain D, general psychiatric disorders, e.g., schizo-phrenia, affective disorders, obsessive compulsivedisorders (OCD), etc; domain E, other childhoodpsychiatric disorders including ADHD, autism, Rettand Asperger disorders, etc.; domain F, miscella-neous, including child abuse, etc. All questions were of multiple-choice type, having four options, and one of them as the most suitable choice. The questionnairewas then reviewed independently by nursing tutorsand experienced (more than 10 years’ practice) childpsychiatrists. Those questions or answers that weredeemed ambiguous or in which there was poor agree-ment among the different reviewers were reworded/replaced with more suitable ones, keeping in mind thecourse content. For the post-test evaluation, the pretestquestions and optional answers were reframed andreworded in order to minimize the practice and carry-over effects. Content validity for both pretest andpost-test questionnaire was established by detaileddiscussion with faculty members experienced in childpsychiatry.  Program evaluation was planned at the time of designing the course content. A total of 30 questions were drafted, covering the CNE topics by the nursing tutors and experienced psychiatrists, in consultation with the resource persons for the program.  Procedure  One hour was given to each participant to completethe pretest questionnaire after explaining the purposeto the participants, on the first day of each program, before commencement of the first lecture. Post-testquestionnaire was given on the last day, after comple-tion of the formal teaching session.  Data Analysis  The statistical package for the social sciencesprogram for Windows (  spss  version 11.0) was used foranalysis of data. Apart from descriptive statistics,    JCAPN Volume 19, Number 1, February, 200625  the Kolmogorov–Smirnov test was used to check fornormal distribution of data in order to select parametric/nonparametric statistical tests. As the scores were notnormally distributed, the Wilcoxon sign ranked testwas used to compare the pre- and post-test scores andthe Mann–Whitney U   test was used to compare themean ranks across different age groups (senior and junior, after a median split of the sample).  Findings  The total sample size was 51. Age range of the par-ticipants was 23 to 57 years (mean [  ±  SD] = 34.69 [  ±  8.09]years), which comprised 3.9% (  n  = 2) men and 96.1%(  n  = 49) women. Out of 51 participants, 67.3% (  n  = 35)were married and 31.4% (  n  = 9) were unmarried. Theeducational qualifications prior to joining nursingwere as follows: 2% (  n  = 12) class 10, 92.2% (  n  = 30)class 12, and 5.9% (  n  = 9) graduate (15 years formaleducation). Most of the participants, 96.1% (  n  = 49)had a diploma in nursing (thereby becoming an RN),whereas 3.9% (  n  = 2) had completed B.Sc. (graduates)in Nursing (thereby, 4 years nursing education after12 years of school education, or 2 years additionaltraining after becoming an RN). Their mean (  ±  SD)experience in psychiatric setup was 6.49 (  ±  7.50) years andexperience in general hospital setup was 3.55 (  ±  6.40)years (Table 1).Analysis of group difference using the Mann–Whitney  U   test revealed significant improvement from totalpre- to post-test   ,  pre- and post-domain C, domain E,and domain F (  p  < 0.001), domain A and domain D (  p  < 0.05). However, no significant difference was seen between pre- and postdomain B scores (Table 2).In order to explore if age has any influence on thelearning capacity during such programs, the groupwas divided, with a median split of age, into twogroups (senior and junior). On exploring group differ-ences, no significant difference was observed in scoresof senior and junior nurses in total pre-, post-test, aswell as in the difference between total pre- and post-test scores. Furthermore, there was no significantdifference between total pretest, post-test, or any of the other domains before or after the program, whichindicates that both senior as well as junior nurses benefited equally from the CNE program (Table 3).  Discussion  The total post-test scores were significantly higherthan total pretest scores (  p  < .001). This indicated thatat the end of the education program, the participantsgained overall knowledge. It was also seen that out of six domains, three showed highly significant improve-ment from pre- to post-test scores (domain C [psy-chopharmacology and management], domain E [other Table 2.Differences in Mean Scores of Different Domains   DomainPretestPost-testImprovement in mean pretest score (%)  z p Total test score13.82 ±  4.5817.94 ±  5.7229.81 − 5.55.000*Domain A score1.80 ±  0.922.43 ±  1.3935 − 2.69.007**Domain B score1.92 ±  0.842.14 ±  1.0011.5 − 1.37.170Domain C score1.98 ±  1.212.86 ±  1.2044 − 4.63.000*Domain D score2.94 ±  1.143.40 ±  1.8815.64 − 1.97.049**Domain E score2.96 ±  1.654.08 ±  2.9437.84 − 3.54.000*Domain F score2.35 ±  1.383.33 ±  1.3441.70 − 4.24.000* (* p < .001 and ** p < .05)
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