Why do so few students prefer psychiatric nursing after graduation? Some clues may be found in

Nursing Students’ Perceptions of the Psychiatric Nursing n 0 hxperience by David I . Pox, Ph.D., Lorraine K . Diamond, Pb.D., Ruth C. Walsh, R.N., M.S., Lucille KnoPf, R.N., B.S., and Jean Hodgin, M.A.

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HE REACTIONS of nursing students to learning experiences in psy- U chiatric nursing and their plans

to seek employment in a psychiatric nursing situation are dependent, to some extent, on their anticipations of the psychiatric nursing experience and, probably to a greater extent, on their actual experiences in psychiatric set- tings. Accordingly, information about student anticipation of and reaction to psychiatric nursing experience has im- plications for both orientation programs and student assignments to psychiatric service. Such information is available from two research studies conducted at the Institute of Research and Service in Nursing Education at Teachers College, Columbia University. The first study, the Stress-Satisfaction Project,' was de- signed to identify the satisfying situ- ations and stressful situations students experience in the basic nursing pro- gram. The Factors and Practices Project,' a follow-up to the earlier project, was designed to identify student factors and nursing practices related to student sat- isfaction in nursing education.

Procedure

Twenty-nine basic nursing programs, 23 diploma and 6 baccalaureate degree programs, participated in the Stress- Satisfaction Project during the academic

1 "Satisfying and Stressful Situations in Basic Programs in Nursing Education," financed by Grant (GN-4485) of the Division of Nursing Resources of the United States Public Health Service.

2 "Factors and Practices Related to Increased Satisfaction and Decreased Stress in Basic Pro- grams in Nursing Education," financed by Grant (GN-6990) of the Division of Nursing Resources of the United States Public Health Service.

year, 1957-58. These schools had been selected by random sampling proce- dures from all basic nursing programs accredited by the National League for Nursing which were located within one thousand miles of New York City. Twenty-three of these programs, 18 diploma and 5 baccalaureate degree, participated in the Factors and Practices Project from 1960 to 1962. Although the unit of sampling was the school, the unit of study was the student of nursing. In all, 4030 students partici- pated in the Stress-Satisfaction Project and 33 16 students in the Factors and Practices Project.

Information on the students' reactions to their psychiatric nursing experiences were secured from four sources: ( 1) a questionnaire which yielded ( 1 ) scaled data on reactions to aspects of the psy- chiatric nursing experience, ( 2 ) written reports of satisfying experiences and stressful experiences on psychiatric units, ( 3 ) group discussions with stu- dents on reactions to their psychiatric nursing experiences, and ( 4 ) responses to a question on the students' plans for careers in nursing.

Nature of Psychiatric Nursing Experience

The majority of the diploma students in the participating schools (71 per- cent) had their psychiatric nursing ex- perience in the second year, and almost all of the others had it in the third year. The majority'of the degree stu- dents (59 percent) had their psychi- atric nursing experience in the third year, and almost all of the others in the fourth year.

Perspectives in Psychiatric Care Volume 111 Number 6 7965 31

In all but one school, students were assigned to one affiliating institution away from the “home” hospital for their psychiatric nursing experience and had field trips for additional experience. An atypical school sent students to three different affiliating institutions. The experience lasted from ten weeks to three months. In all of the diploma programs and some of the degree pro- grams, the clinical instructors in psy- chiatric nursing were on the staf€ of the affiliating institutions; in some degree programs, an instructor from the college accompanied students to the psychiatric facility.

Reactions to Psychiatric Nursing Experience

The students’ reactions to psychi- atric nursing experience were obtained in the late spring of 1961, when 2895 students, or 87 percent of the 3316 students then enrolled in the 23 schools participating in the Factors and Prac- tices Project, completed the Nursing School Experience Sheet, or NSES. Of the 2895 students, 1149 had had ex- perience in psychiatric nursing.3 On the NSES, students indicated their reaction, on a seven-point stress-satis- faction scale, to 236 aspects of nursing school experience, nine of which con- cerned experience in psychiatric nurs- ing. These nine aspects were “psychi- atric experience in general” and eight specifics of psychiatric experience: “thoughts before going on psychiatry,’’ “first day in psychiatry,” “orientation,” “supervision,” “caring for psychiatric patients,” “relationships with patients,” “relationships with nursing st&,” and the “recovery rate in psychiatry.”‘

For purposes of data analysis, a re- action of “completely satisfying” or “much more satisfying than stressful” was considered a predominantly satis- fying reaction; a reaction of “completely stressful” or “much more stressful than satisfying” was considered a predom- inantly stressful reaction; and a reaction of “equally satisfying and stressful” or “slightly more” satisfying or stressful was considered a mixed reaction.

Since there were no significant dif- ferences between the response patterns of the diploma and the degree students to the items on psychiatric nursing, or of students who had had the experience in the junior and senior years, the re- sponses of students in all years in pro- grams of both types were combined.

As can be seen from TABLE I, two- thirds (64 percent) of the students reported a predominant satisfying re- action to their psychiatric experience in general, almost another third (30 percent) a mixed reaction, and 6 per- cent a predominantly stressful reaction.

Three specifics, “caring for patients,” “relationships with patients,” and “re- lationships with nursing staff ,” elicited the same response pattern as did the over-all experience; about two-thirds of the students recalled each aspect as satisfying, about one-third had a mixed “he development of the NSES is presented in

detail in “Correlates of Satisfaction and Stress with Nursing School Experience,” by David J. Fox, Lorraine K. Diamond, Ruth C. Walsh, Lucille Knopf, and Jean Hodgin, Narsing Research, Spring 1963, Vol. 12 No. 2.

4 A complete discussion of student response on the NSES appears in “The Potential for Satis- faction and Stress of Selected Aspects of Nursing School Experience,” by David J. Pox, Lorraine K. Diamond, and Ruth C. Walsh, Institute of Research and Service in Nursing Education, Teachers College, Columbia University, New York, June 1962.

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reaction, and from 3 percent to 4 per- cent had a stressful reaction. Two other specifics, “supervision” and “orienta- tion,” had about the same stress poten- tial ( 5 percent to 6 percent) as the psychiatric experience in general and the above three specifics, but had some- what lower satisfaction potential, “su- pervision” being satisfying to 58 per- cent of the students and “orientation” to 48 percent.

Responses to the two items concerned with initial psychiatric experiences, “thoughts before going on psychiatry” and “the first day in psychiatry,” in- dicate that students tend to find these experiences stressful. Almost one-third of the students found their “anticipatory thoughts” and their “first day in psj- chiatry” predominantly stressful, and less than one in five reported a pre- dominantly satisfying reaction. The high stress in low satisfaction potential

was even more marked in the students’ reactions to “the recovery rate in psy- chiatry,” with one-third of the students reporting a stressful reaction and only one in ten a satisfying reaction.

The relationship between student re- actions to the psychiatric experience in general and to the specifics of this ex- perience was determined by computing rank-order correlations between the re- sponses of students in each school to the general item “your psychiatric nurs- ing experience” and the responses of students in the school to each of the eight specific aspects of the e~perience.~ Except for “relationships with nursing staff on psychiatric units,” all of the reactions to the specific aspects were significantly related to the general re- action to the psychiatric experience. There was a significant correlation be- tween the general reaction and the re- action to “orientation” (.8 1 ) , “caring

TABLE 1

REACTION OF STUDENTS TO PSYCHIATRIC NURSING

Your psychiatric experience

Relationships with psychiatric

Relationships with nursing staff

Caring for psychiatric patients The supervision you received

during psychiatry The orientation received

for psychiatry Your thoughts before going

on psychiatry Your first day in psychiatry The recovery rate in psychiatry

in general

patients

on psychiatric units

NUMBER OF

RESPONDING STUDENTS

1124

1124

1119 1123

1122

1126

1173 1127 1119

PERCENT OF RESPONOINC STUDENTS WHOSE REACTIONS WERE:

PREDOMINANTLY STRESSFUL

6

3

3 4

6

5

29 31 33

MIXED

30

34

31 33

36

47

53 53 57

PREDOMINANTLY SATISFYING

64

63

66 63

58

48

18 16 10

Perspectives in Psychiatric Care Volume 111 Number 6 1965 33

for psychiatric patients” (.80), “first day in psychiatry” ( .74) , “supervision” ( .67 ) , “the recovery rate in psychiatry” ( .63 ) , “relationships with psychiatric patients” (.%> , and “thoughts before going on psychiatry” ( .5 1 ) . Thus, stu- dents’ over-all reactions to their psy- chiatric nursing experience reflected their feelings about all the specifics studied except “relationships with nurs- ing staff.” In other words, regardless of the kind of reaction the students in a school had to their psychiatric nursing experience in general, they did not necessarily have parallel feelings about their relationships with the nursing staff in the psychiatric setting.

Satisfying and Stressful Experiences

Information about satisfying experi- ences and stressful experiences in psy- chiatric nursing were obtained during the Stress-Satisfaction Project in which 4030 students completed incident schedules from one to four times during the 1957-58 school year. Of these, about 1600 had had psychiatric nursing ex- perience. Each incident schedule asked students to describe in detail a recent satisfying situation and a recent stress- ful situation that they had experienced.“ Of the over 8600 satisfying and 8600 stressful incidents reported by students, 300 satisfying and 370 stressful in-

,; A complete discussion of correlates of student reaction to nursing school experiences appears in “Correlates of Stress and Satisfaction in Nursing School Experience,” by David J. Pox, Lorraine K. Diamond, and Ruth C. Walsh, Institute of Ressearch and Service in Nursing Education, Teachers College, Columbia Uni- versity, New York, July, 1962.

cidents were directly concerned with experience in psychiatric nursing.

Since the content of the incidents reported by students in the diploma and the degree programs was similar, the responses of these two groups will be discussed together. The stressful in- cidents about psychiatric nursing ex- periences related to anticipatory fears about psychiatry, the condition of the patients, the patients, behavior, and components of patient care. These var- ious sources of stress are illustrated by the following reports of incidents.

Several reports of stressful incidents reflected anticipatory fears about psy- chiatric nursing. Some students had a generalized fear of the unknown; others were afraid that they would not be able to talk to mentally ill patients; some did not know what kind of behavior to expect from the patients; and a few students feared that they, themselves, might become mentally ill.

My first few weeks on psychiatry were stressful because I didn’t know exactly what to expect from the pa- tients. Neither did I know quite how to approach them or how to get them to do things or, for the most part, to even talk with them. (Di-2)‘

At first when I started in psychiatry, I had a little fear. In my mind, scenes from the movie “Snake Pit” and the like made me quite apprehensive. Then, “The complete report of this project appears in

“Satisfying and Stressful Situations in Basic Programs in Nursing,’’ by David J. Fox and Lorraine K. Diamond, Teachers College Bureau of Publications, Teachers College, Columbia University, New York, December 1964. The program and year in school of the student writing each incident will be indicated using “Di” for diploma program and “De” for degree program.

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upon arrival and seeing the patients - some very “natural,” others depressed, elated or confused - seemed to make a great feeling of sympathy within me. ( Nevertheless, though there were mo- ments where I thought I was no use, I felt within a great need to help these people). (De-3)

Some students expressed their dismay over the condition of the patients, whom they saw as hopeless, unap- proachable, removed from reality, or unresponsive to students’ overtures. Although most students tried to handle these situations, some described their feeling of inadequacy or their desire to avoid the patient.

While on a psychiatric nursing affili- ation, I had an elderly woman as a patient. Every time I went near her she would scream and become very comba- tive. I went out of my way to be nice to her, but it just didn’t work out. It got so bad that I just avoided her and she was assigned to another student. I got very impatient when working with her and often felt like screaming my- self. (Di-2)

I was a new student on psychiatry; my assignment was a character disorder, a teen-ager. She rejects people before they have a chance to reject her. Thus she rejected me - I could not establish a working relationship with her until four days had passed. During the first four days I was completely rejected by the patient, and although 1 knew that this was part of her disease process, I felt inadequate and a failure as a nurse - for four days at least. (De-3 )

Patient behavior also was perceived as distressing when patients were un- controllable, aggressive, or potentially suicidal, or when male patients acted out in a sexual manner.

At the psychiatric hospital I was watching a lady who, just as I turned my head, ran into the kitchen and got a knife. 1 tried to conceal my nervousness and act calm, and somehow was able to acquire the knife from her. This was the first time anything like that hap- pened to me; it was quite an experi- ence. (De-2)

A patient on the chronic floor of the mental hospital drank 200 cc. of am- monia one morning, trying to commit suicide. The doctors pumped her stom- ach. For weeks later she could not swallow, talk very well, or sleep a complete night through. It was stressful to see her in this condition. (Di-3)

While I was in psychiatry, a young male patient continually tried to expose himself. There was very little that could be done to distract him, in the way of activities. ( Di-3 )

For some students, aspects of patient care, such as shock therapy or incon- siderate treatment of patients by staff, were sources of stress.

On my psychiatric &iliation I met a very distressing situation for me. It was my experience in the electric shock therapy room. Something about the treatment frightened me. I felt weak - my heart beat fast - I almost felt like fainting and, as much as I tried, I could not convince myself that this treatment helps. (De-4)

Perspectives in Psychiatric Care Volume Ill Number 6 1965 35

During the past three months I was on psychiatric affiliation. The general care and treatment of the patients at the hospital was very stressful to me. They were not treated at all like human beings. ( Di-3 )

Satisfactions with psychiatric nursing experience came chiefly from four sources: positive student-patient rela- tionships, patient recovery, good rela- tionships with psychiatric hospital staff, and good evaluations.

When a student was able to com- municate with a patient who had been very withdrawn or when a patient sought a relationship with the student, the student expressed satisfaction with patient care. An added satisfaction was a patient’s expression of appreciation for a student’s care and attention.

In psychiatry I worked with a pa- tient who was withdrawn and aloof. After working with her and always taking the first approach, I was very pleased the morning she felt our re- lationship was strong enough to ap- proach me first. (De-3)

I was working on the psychiatric division, and I was observing a patient with a diagnosis of catatonic schizo- phrenia. She had not spoken since her admission. No one knew if she could or could not speak. Each day I would sit beside her for about 10-1 5 minutes and would talk to her. She never looked at me or said anything. After about three weeks, I had almost lost, hope. During the fourth week she came up to me, called me by name, and asked me a question. (Di-2)

When a patient made sufficient prog- ress to go from a locked to an open hall or to go out on a pass or to be discharged it was very gratifying to students.

A satisfying situation occurred while I was working in psychiatry. I worked with a very withdrawn and rejecting patient quite intensively for a few weeks, and gradually, by planning ahead and using knowledge I had gained in my classes, I felt that I was able to draw him out. He improved to the point of being discharged. (Di-2 )

A psychiatric patient was moved to the open hall from the locked hall, due to the combined efforts in which I played a part. (De-4)

Relationships with psychiatric hos- pital staff were satisfying when students were treated like adults, found staff willing to answer questions, or received good evaluations from them.

On psychiatric affiliation everyone was so friendly, accepted your opinions, and treated you like a responsible per- son. (Di-2)

I was told by the instructor in psy- chiatric nursing that I was an emotion- ally mature person who could readily adapt myself to almost any situation, especially those which pertained di- rectly to either the emotional or phy- sical well-being of the patient. She said that I gave readily of myself and that several patients had told her that I was one of the warmest nurses that they had known. (Di-2)

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One other satisfaction expressed in a few reports of incidents was that the students felt better able to understand behavior after their psychiatric nursing experience .

The most satisfying event that hap- pened these past three months is my affiliation at a mental hospital. Here I found great joy working with the mentally ill. At the same time I learned many new aspects of understanding others and acceptance of others through understanding myself. It has made me more aware of the emotional behavior seen in patients in general hospitals and gave me a means to work with and understand them. (De-3 )

Group Discussion Data

During the spring of 1962, upper- classmen in the 23 participating pro- grams met in small groups with the research staff to discuss their reactions to selected aspects of nursing school experience. Psychiatric nursing experi- ence was selected for discussion in nine schools in which the students’ reactions differed from the normative reaction based on the combined responses of students in all 23 schools. The students in some of these schools found psychi- atric nursing experience more satisfying than did students in most schools, whereas the students in the other schools found the experience more stressful than did those in the average school. The students discussed several aspects of psychiatric nursing experi- ence including the administrative ar- rangements for the psychiatric d i l i - ation, the role of classes and super-

vision, anticipatory fears before and when just beginning the psychiatric ex- perience, aspects of patient care, and values gained from their psychiatric experience.

Considerable discussion centered on administrative arrangements, which were satisfying to some students and stressful to others. Some students looked forward to the change of locale, where- as others objected to the disruption in routine, especially when it meant ad- ditional expense. Some groups said rules were more lenient at the affili- ating institution than at the home school and therefore more satisfying; others thought that rules at the psychi- atric hospitals were more strict and therefore more stressful. In some affili- ating hospitals, nurses did not wear uniforms, thus adding to the students’ ill-at-ease feelings in the new situation. In some settings so many students were assigned to a unit at a given time that, on occasion, the students outnumbered the patients. Still another adjustment that was d8icult for some students was the actual lack of specific work tasks on the psychiatric units.

During the group discussions, the students echoed the same anticipatory fears about psychiatry as were described in the incidents written by students four years earlier. The contribution of stu- dent grapevine information to antici- patory stress was particularly mentioned during interviews.

In discussing the classes and super- vision in psychiatric nursing, the stu- dents reported satisfaction when in- structors were highly motivated and when learning could be related to spe- cific patients. Some students felt that

Perspectives in Psychiatric Care Volume Ill Number 6 1965 37

clinical instructors in psychiatry were more understanding of students and their nursing care problems than were clinical instructors in other services, and this held for other psychiatric hospital staff as well. Students generally felt they were accepted by both clinical instructors and hospital staff as part of the treatment team and as contributing members of patient care conferences. Stressful experiences included reading and written assignments which were too lengthy or had no application to the patient care experiences. In addi- tion, some students resented the fact that they worked mainly with techni- cians and were without professional supervision.

The group discussion data confirmed the incident data in that caring for psychiatric patients was generally satis- fying when students felt that they could communicate with patients, that they had contributed to the patients’ well- being, and that progress in the patients’ conditions was detectable. Patient care became stressful when patients did not improve or were readmitted and when students observed electric shock treat- ment.

In the discussions, the students men- tioned other positive and negative re- actions to their psychiatric nursing ex- perience. They generally were of the opinion that, as a result of their psy- chiatric experience, mental illness was not the frightening, mysterious entity they had presupposed; they had learned tolerance and compassion; they would be better able to care for all patients in the future; and the intense con- centration upon the observation and study of behavior and emotions during

their psychiatric experience had made them more introspective. On the other hand, the students expressed the belief that their new knowledge about human behavior could be a source of confusion as well as of illumination, and that the increase in introspectiveness could have negative as well as positive effects.

Career Plans

Data on career plans were obtained during the fall of 1961, when 2808 students (77 percent of the 3624 stu- dents who were at that time enrolled in the 23 schools) completed the Nurs- ing School Information Sheet, a ques- tionnaire concerned with the students’ socio-educational background, reactions to nursing, and plans for the future.

The students indicated on the Nurs- ing School Information Sheet whether or not they planned, to work as nurses in the year after graduation and, if so, the position they expected to hold and the hospital service they would prefer. A large majority (95 percent) of the students planned to work as nurses im- mediately after graduation, and 82 per- cent of these students expected to obtain staff nurse positions in the hospitals, while 4 percent expected to be head nurses. Of the students who planned to work as nurses after graduation, 5 per- cent indicated a preference for a psychi- atric service, in contrast to the 37 percent who preferred medical-surgical nursing, the 20 percent who preferred pediatric nursing, the 13 percent who preferred obstetric nursing, the 8 percent who preferred working in the operating room, and the 17 percent who preferred other special services or non-hospital

38

positions.8 A more relevant basis for comparison is the number of students who already had had psychiatric nurs- ing experience, of whom approximately 10 percent indicated a preference for psychiatric nursing.

Discussion The data presented here have identi-

fied the varied, and often contradictory, reactions that nursing students have to their psychiatric , nursing experience. The data show that the majority of the nursing students in this study found their psychiatric nursing assignment a predominantly satisfying experience. Furthermore, these students found most of the specific aspects of their psychi- atric nursing assignment satisfying. Nevertheless, when asked to describe satisfying experiences and stressful ex- periences in nursing school, the students reported more stressful than satisfying incidents in connection with their psy- chiatric nursing experiences. Moreover, few students planned to seek employ- ment in psychiatric nursing situations after graduation. Apparently many complex factors contribute to nursing students’ perceptions of psychiatric nursing.

These combined data about student nurses’ perceptions of the psychiatric nursing experience present some im- plications for both general education and nursing education.

In recent years, many mass media campaigns have been conducted in an effort to increase public understanding of mental illness. It is questionable how effective these efforts have been in reaching the student nurse group prior

8 There were no statistically significant differ- ences between the preferences of diploma and degree students.

to their first contact with the mentally ill. As far as the students in this study were concerned, patients on the psy- chiatric service were strange, fright- ening, and potentially dangerous.

Although many psychiatric hospitals now have open wards, a high propor- tion of the students surveyed had their experience on locked wards, or had their affiliation in a hospital which did not have an open-ward policy, Natu- rally, the already apprehensive begin- ning students observed that the patients were not only separated from society, but also kept locked in, and thereby the students’ fears were heightened.

It speaks well for the students, their ability to learn, and their ability to grow in their professional role that usually by the time their experiences in the psychiatric facility were over, many of these widely prevalent cultural fears were overcome. Students generally attributed the change in attitude to practical experience with patients; less frequently they mentioned the psychi- atric nursing course as influencing their perceptions. However, it is possible that the students were not overtly aware of, and could not identify, the influ- ences their educational program had on them.

Not only did the students relinquish some of their cultural stereotypes about the mentally ill, but there were also certain accepted nursing expectations which they revised during their experi- ences in psychiatric settings. Having had most of their prior clinical work on the general hospital units, the stu- dents had become accustomed to having specific assignments and predetermined tasks to ‘accomplish in a specified amount of time. When they were as-

39 Perspectlves in Psychiatric Care Volume 111 Number 6 1965

signed to psychiatric units, they had very few familiar nursing tasks to per- form. They were not able to relate to patients through the vehicle of a tech- nical skill or procedure, and therefore they often felt psychologically deprived of the nurse's role as they had learned it. Thus, in the psychiatry setting they had to give up their customary profes- sional tools and adopt new verbal and emotional ones.

Another expectation the students had to alter was the view, common to all in the healing profession, that the patient will recover. For the most part, patients in the general hospital do recover. How- ever, psychiatric patients do not follow the expected norm: they do not recover in the sense that they get well quickly or that they become completely free of symptoms.

It is feasible to expect that a pro- gram of instruction and orientation could minimize the unproductive stresses from the fears and expectations identified in this study. Such orientation programs should focus on student fears anticipatory to the psychiatric assign- ment, on the role of the nursing student on the psychiatric units, and on the prognosis for patient improvement and recovery. Such orientation is desirable for all student nursing assignments, but it appears to be an absolute necessity for helping the students to adjust to psychiatric nursing.

Orientation programs not only should focus on the sources of stress and try to overcome them, but also should focus on the sources of satisfaction in psy- chiatric nursing and try to strengthen them. Satisfactions from patient care and recovery, from relationships with staff, and from new insights and under-

standings were dominant in the in- cidents reported by students.

Administrators and educators con- cerned with staff ing psychiatric units should be aware that only a small pro- portion of the students, about one in twenty of all students and one in ten of those who had psychiatric experience, indicated a preference for working on the psychiatric service after graduation from nursing school. Considering the number of psychiatric facilities now in operation and the ever-increasing num- ber of psychiatric units that are being established in general hospitals, serious study should be devoted to discrepancies between the proportion of future nurses preferring psychiatric nursing and the present and future personnel needs of institutions. There is also a wide and unexplained discrepancy between the proportion of students reporting satis- faction with their psychiatric experience (more than 60 percent) and the pro- portion expressing preference for work- ing in psychiatric situations after grad- uation ( 10 percent).

The data have indicated that in spite of their initial fears and adjustment problems, the students in this study learned to relate to psychiatric patients and were able to perceive of themselves as having been of some help to patients. Most of these students felt that they had gained new, different, and helpful insights and skills while on the psychi- atric service. Awareness of both stu- dents' problems with psychiatric nursing and the great potential for satisfaction which caring for psychiatric patients has should further strengthen educa- tional programs and may increase the proportion of students intending to spe- cialize in psychiatric nursing.

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