CNE Activity

CNE Activity

  • Journal of Psychosocial Nursing and Mental Health Services
  • January 2012 - Volume 50 · Issue 1: 25-38, 41-49
  • DOI: 10.3928/02793695-20111219-50
Rights and Permissions

Instructions

4.0 contact hours will be awarded by Vindico Medical Education upon successful completion of the posttest and evaluation. To obtain contact hours:

  1. Read the following articles carefully, noting the tables and other illustrative materials, which are provided to enhance your knowledge and understanding of the content:

    • Discrimination Against South African Adolescents Orphaned by AIDS

      Gloria Thupayagale-Tshweneagae, RN, MNS, DTech; and Zitha Mokomane, PhD, on pages 26–31.

    • Disrupted by Disaster: Shared Experiences of Student Registered Nurse Anesthetists Affected by Hurricane Katrina

      Marjorie A. Geisz-Everson, CRNA, PhD; Marsha J. Bennett, DNS, APRN, ACRN; Diane Dodd-McCue, DBA; and Chuck Biddle, CRNA, PhD, on pages 32–38.

    • Revising a Medication Education Program on an Inpatient Child and Adolescent Psychiatric Unit

      Carmen M. Eisenmann, MSN, RN-BC, on pages 41–47.

  2. Read each question and record your answers on the CNE Registration Form on page 49.

  3. Complete all sections of the CNE Registration Form, including indicating the total time spent on the activity (reading articles and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

Contact Hours

Vindico Medical Education is an approved provider of continuing nursing education by the New Jersey State Nurses Association, an accredited approver, by the American Nurses Credentialing Center’s Commission on Accreditation, P188-6/09-12. This activity is co-provided by Vindico Medical Education and the Journal of Psychosocial Nursing.

This is a Learner-Paced Program. Answers to the posttest will be graded, and you will be advised that you have passed or failed within 60 days of receipt of your completed test. A score of 70% or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the test. A contact hour is 60 minutes of instruction. Contact hour verification can be awarded only at the completion of a program.

Activity Objectives

  1. Describe how discrimination impacts the lives of South African adolescents orphaned by AIDS.

  2. Identify ways in which faculty can assist college students following a disaster.

  3. Describe teaching strategies that can improve effectiveness of medication education.

Author Disclosure Statements

  • Dr. Thupayagale-Tshweneagae and Dr. Mokomane disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Tshwane University of Technology sponsored Dr. Thupayagale-Tshweneagae’s doctoral studies.
  • Dr. Geisz-Everson, Dr. Bennett, Dr. Dodd-McCue, and Dr. Biddle disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. This article was written as part of the requirements of an MSN completion from the University of Saint Francis, Fort Wayne, Indiana.
  • Ms. Eisenmann discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. This article was written as part of the requirements of an MSN completion from the University of Saint Francis, Fort Wayne, Indiana.

Commercial Support Statement

All authors and planners have agreed that this activity will be free of commercial bias. There is no commercial support for this activity. There is no non-commercial support for this activity.

Discrimination Against South African Adolescents Orphaned by AIDS

In many developing countries, HIV-related stigma and discrimination are major challenges to the welfare of adolescents orphaned by AIDS. Orphans are often overworked, have lower access to education and health services, and are more often denied inheritance of their parents’ property. Female orphans are particularly at risk for sexual abuse, which increases their vulnerability to HIV infection (Economic Commission for Africa, 2004). Studies have also shown that HIV-related stigma and discrimination can lead to psychological distress and negative mental health well-being (Cluver, Fincham, & Seedat, 2009; Deacon & Stephney, 2007; Stutterheim et al., 2009). Despite this evidence, much of the research on HIV-related stigma and discrimination has been on adults; specific research among children and adolescents is relatively sparse (Deacon & Stephney, 2007). The purpose of this article is to fill this research gap by exploring how adolescents orphaned by AIDS express their experiences of and feelings about being discriminated on. This work stems from a study conducted to develop a peer-based mental health support program for adolescents orphaned by AIDS.

Background

Given the tendency of the HIV and AIDS pandemic to strike young adults, AIDS-related deaths in many developing countries leave significant number of orphans in its wake (Nhate, Ardnt, Barslund, & Van den Broek, 2005). The majority of these orphans are in sub-Saharan Africa, with the region accounting for 90% of the estimated 16.6 million global AIDS orphans in 2009 (Joint United Nations Programme on HIV/AIDS, 2010). National policy in highly afflicted African countries favors the integration of orphans into substitute or extended families (Nhate et al., 2005), and this largely explains why more than 90% of orphaned children in many African countries live with extended families (Save the Children UK, 2007). Although this approach has the advantage that children remain integrated within a family (Nhate et al., 2005), available evidence shows that children orphaned by AIDS often face abuse, neglect, and discrimination due to the stigma related to HIV and AIDS. A study in Guinea, for example, found that 70% to 80% of children orphaned by AIDS reported that they had been abandoned, criticized, insulted, or neglected (Delva, 2010). High levels of discrimination have also been noted in other African countries such as Mozambique (Nhate et al., 2005), Malawi (Funkquist, Eriksson, & Muula, 2007), Uganda (Cluver, Gardner, & Operario, 2008), and South Africa (Onuoha, Munakata, Serumaga-Zake, Nyonyintono, & Bogere, 2009).

Method

Setting

The study took place in 2007 at an AIDS awareness center run by a nongovernmental organization in a township 35 kilometers from the South African capital, Pretoria. The facility serves as a day care center and hospice for feeding and providing social support for terminally ill individuals and their families, people living with HIV and AIDS, and orphans. At the time of the study, 250 orphans were served at the center, of which 150 were orphaned by AIDS.

Sample

Fifteen adolescents orphaned by AIDS were recruited from the center for the study. The recruitment process began with the principal investigator (G.T.-T.) explaining the objectives of the larger study to the center management. The management was then given a client information leaflet to distribute among orphans at the center to solicit their voluntary participation in the study. The leaflet outlined—in detail—the purpose and objectives of the study, the study duration, participants’ rights, assurance of confidentiality, and ethics approval of the study, among other items. It also specified the inclusion criteria for the research participants, which were to be ages 14 to 18, to have been orphaned for more than 1 year, to attend the AIDS awareness center regularly (at least once per week), and to be willing to participate in the study. By the end of the recruitment process, 25 orphans had shown interest in taking part in the study. However, only 15 met the inclusion criteria. The other 10 were either too old or young, and some did not attend the center regularly.

Data Collection

Data were collected using reflective diaries, which are “self-report instruments used repeatedly to examine ongoing experiences, [and which] offer the opportunity to investigate social, psychological, and physiological processes, within everyday situations” (Bolger, Davis, & Rafaeli, 2003, p. 580). For this particular study, the diaries were meant to help participants write down the details of how they believed they were being discriminated on and how that discrimination was associated with the loss of their parents to AIDS.

The research participants were given small notebooks to serve as diaries. They were then asked to record their feelings and thoughts on whether they experience any discrimination and whether they think they are being discriminated on because their parents died of AIDS. The grand tour prompt for this study was “Write in your diaries weekly on how you feel discriminated on because your parent(s) died of HIV.” Discrimination was defined by the authors for this study as “unfair and unjust treatment of an individual based on the fact that a person had been orphaned by AIDS.” Participants’ diaries were checked and read every week by the principal investigator. The purpose was to examine the participants’ entries for focus. Participants were asked to use pseudonyms, known only to the researcher. Participants handed in their diaries at the end of the 6-month data collection period.

Data Analysis

Thematic analysis was performed using Colaizzi’s (1978) seven steps method:

  • Step 1: Reading of transcripts. The principal investigator reads and re-reads all of the participants’ diaries to acquire a sense of the way the adolescents expressed their views on being discriminated on.
  • Step 2: Extracting significant statements. The researcher extracts from the transcripts all key statements that relate directly to the study theme (Colaizzi, 1978). Significant meanings are then extracted from the descriptions as expressed in the diaries.
  • Step 3: Formulating meanings. In line with the key tenets of Colaizzi’s (1978) method, meanings are formulated from the participants’ statements in the diaries.
  • Step 4: Theme clusters. The researcher organizes the formulated meanings into groups, which allow themes to emerge (Colaizzi, 1978). Thus, the meanings formulated in Step 3 are grouped into theme clusters.
  • Step 5: Exhaustive description. The principal investigator integrates the themes into an exhaustive description of the participants’ written statements.
  • Step 6: Statement of identification. The researcher makes a succinct statement of the exhaustive description and provides an essential statement of identification. The descriptions lend themselves to the discovery of the adolescent orphans’ views about being discriminated on.
  • Step 7: Participant verification. Colaizzi (1978) proposed that the researcher corroborate the information, written up in a short statement, by asking the participants what features of their experience have been left out. None of the participants disagreed with the researchers, but a few participants recommended minor changes to the wording.

Ethical Considerations

The Ethics Committee of the participating university granted the researcher permission to conduct the study. In addition, data collection was undertaken in line with principles of ethical research involving human subjects. These principles include special attention to communicating the aims of the study, the rights of people participating in the research, written informed consent, and confidentiality. In particular:

  • It was explained and emphasized to the participants that participating in the study was voluntary, and that those who did not want to participate would not be treated any differently by the researcher or the staff at the AIDS awareness center.
  • The participants were informed that they could withdraw from the study at any time if they wished.
  • The researcher assured the participants that information obtained would not be shared with strangers or people known to the participants, such as family members.
  • Assurance was given that identifying information would be stored in such a way that it would not be accessible to anybody in the AIDS awareness center.
  • The participants were given the contact information of the researcher and the researcher’s supervisors so they could contact them in the event of any further questions, comments, or complaints.
  • It was explained to participants that in the event that writing in the diaries elicited the recall of specific traumatic events, the participant could talk to the researcher at any time during the study period. Where deemed necessary, a referral to an appropriate professional would be availed at no cost to the participant.
  • Finally, written informed consent was obtained from participants and their guardians.

Findings

Although all 15 participating adolescents had agreed to write their experiences and thoughts of being discriminated on in their diaries, only 8 (5 girls and 3 boys) submitted completed diaries at the end of the 6-month data collection period. The 7 (5 girls and 2 boys) who submitted empty diaries explained that it had been very difficult for them to write their thoughts, as they were still struggling to accept their parents’ death. This is consistent with some arguments in the literature that discrimination associated with HIV and AIDS can lead to distress and anger that may not be easy to document (Baingana, Thomas, & Comblain, 2005).

Examination of the entries in the diaries revealed a range of experiences with discrimination that can be categorized into three broad themes: Experiences with New Families, Experiences at School, and Experiences with Other Orphans Whose Parents Did Not Die of AIDS. There were no major variations in the experiences and feelings of the adolescents by age or gender.

Experiences with New Families

In the entries that described the experiences of life with new families, the overall perception among the orphaned adolescents was that caregivers demonstrated preference for their own children. As one participant wrote:

This week was as bad as others, my grandmother is tired and at times blames me for my mother’s death, my uncle abuses me and calls me names as if I am the one who died of AIDS, my friends no longer visit because I am not allowed to play for fear that I will die like my mother. It hurts me, I am an outcast. I feel life will never be the same for me.

My life has never been the same since my parents died. For a year I was forced out of school because my aunt said she cannot feed me and pay a maid as well, so I have to be out of school to allow my cousin [aunt’s daughter] to finish school.

In another case, an adolescent orphan noted that his aunt left him alone whenever the family went on holiday: “I get left out when they go on holidays to guard the house.”

Some relatives were noted to complain about the new living arrangements, as one 18-year-old boy wrote about what his cousin had said to him: “Do you know that your mother died of AIDS? Now you have taken over our house, I no longer have a room for myself.”

Experiences at School

The assumption in many settings is that teachers have functional knowledge about HIV and AIDS (Visser, 2004), particularly since the school should be a place where children’s resilience and ability to face daily life situations are supported (Duncan & Van Niekerk, 2001). However, the entries in many of the diaries showed that adolescents orphaned by AIDS are often discriminated on by teachers and schoolmates. For example, a teacher revealed both prejudice and ignorance when she said to one of the study participants: “Be careful not to let other pupils use the same spoon as you.” Similarly, an 18-year old boy participant wrote:

I used to do very well at school, I had nice shoes and my uniform was always neat. When my mother was alive I would eat breakfast in the morning; I used to eat bread with butter and have milk or tea. My teacher also liked me, because she liked my mother. Nowadays my teacher does not care about me, she even tells other students not to eat from my plate.

Five of the participants wrote that some teachers, while trying to be kind, would embarrass them by singling them out for special treatment in the presence of others, such as frequently enquiring about the welfare of the orphaned adolescents or giving them money for school uniforms, sports, and other things. Although the offerings were viewed as generous, the recipients did not like being singled out, even among the poorer children of the class. Participants also reported that classmates made hurtful remarks to them, and some would shun them by keeping their distance from them as though they were contagious or contaminated.

Experiences with Other Orphans Whose Parents Did Not Die of AIDS

At times, the study participants experienced discrimination from other orphans whose parents had died of causes unrelated to HIV or AIDS. For example, at places such as the AIDS awareness center, where the orphaned adolescents went for weekend meals and counseling, they were often subjected to comments such as “Why should we mix with them?” and “People should not confuse me with you; my mother died in an accident.”

Discussion

The entries in the orphaned adolescents’ reflective diaries affirm previous research findings that the very people whom one would expect to support children orphaned by AIDS—extended family members, caregivers, teachers, and even peers—were often responsible for acts of abuse, neglect, and discrimination (Delva, 2010). One interesting finding of this study was that one of the orphaned adolescents mentioned that her grandmother is always tired and at times blames her for the death of her mother. This gives thought to the fact that the grandmother may still be grieving the death of her daughter. Moules, Simonson, Prins, Angus, and Bell (2004) asserted that society only recognizes grief in an individual when it becomes problematic. Cultural expectations often dictate that a grieving individual should get over the loss and not continue feeling grief for an extended period (Rosenblatt, 1995). As a result of these cultural expectations, grieving individuals learn to hide their grief from the public and internalize it. It is this internalization of grief that leads to withdrawal, isolation, and depression (Moules et al., 2004). Demmer (2004) pointed out that those individuals who grieve over an AIDS-related death confront many issues that may complicate their grieving process. Such issues may include inadequate social support; for example, the grandmother mentioned above may be overwhelmed with caregiving responsibilities.

Although the discrimination that these orphaned adolescents experienced is not a unique finding of this study, using reflective diaries allowed participants to express their thoughts, emotions, and feelings with minimal distortion. The findings of this study suggest that the reflective journal is a valuable instrument to aid reflection. It also assists in placing thoughts and feelings in perspective, allowing for healing for those who use it. Writing in the diaries not only encouraged disclosure (Chirema, 2007), but as a mental process, it also afforded participants some form of relief from their pain.

Overall, the reflective diary entries succinctly showed that adolescents orphaned by AIDS are experiencing many stressors. For example, they need to feel a sense of connectedness with their caregivers, and a failure in this area affects their feelings of security. This finding is consistent with Erikson’s (1982/1987) theory of adolescent development, which emphasizes a strong parental bond as ensuring a positive identity that yields feelings of security. When stigmatization and discrimination are strong, it can easily be internalized by the orphans. This may result in severe emotional/psychological pain and suffering, leading to self-induced isolation and self-perceived stigma, all of which can lead to depression and anxiety (Wood, Chase, & Aggleton, 2006; Yale School of Public Health, Center for Interdisciplinary Research on AIDS, 2007).

Study Limitations

Given the need for more research on HIV-related stigma and discrimination among adolescents, this article provides valuable insights. However, the results should be interpreted with caution, given the study’s limitations, particularly the small sample (also drawn from a small locality), which limits generalization of the findings to other populations. Therefore, a larger study should be conducted to reaffirm the conclusions of the study.

Implications for Nurses

The findings of this article underscore the need for the involvement of psychosocial and mental health nurses in the assessment of orphan placement, to ensure family support and caregiver commitment from a psychological viewpoint. It is also important to recognize that educators alone cannot quell the challenge of helping adolescents cope with environmental and social stressors, such as discrimination.

Conclusion

South African adolescents orphaned by AIDS still fall victim to discrimination, despite widespread knowledge of the mode of transmission of HIV and the availability of antiretroviral drugs. This has been well demonstrated by documentary evidence from orphaned adolescents in South Africa. This situation needs urgent intervention to protect orphaned adolescents and ensure they are able to enjoy life like all other people. It is the authors’ contention that a peer-based mental health program designed for this group will go a long way toward helping orphaned adolescents transcend issues of discrimination and talk openly about AIDS as the cause of their parents’ death. Open communication will also make it possible for these adolescents to be supported and to achieve a better and more positive understanding of HIV and AIDS.

References

  • Baingana, F., Thomas, R. & Comblain, C. (2005). HIV/AIDS and mental health. Retrieved from The World Bank website: http://siteresources.worldbank.org/HEALTH-NUTRITIONANDPOPULATION/Resources/281627-1095698140167/BainganaHIVAIDSMH.pdf
  • Bolger, N., Davis, A. & Rafaeli, E. (2003). Diary methods: Capturing life as it is lived. Annual Review of Psychology, 54, 579–616. doi:10.1146/annurev.psych.54.101601.145030 [CrossRef]
  • Chirema, K.D. (2007). The use of reflective journals in the promotion of reflection and learning in post-registration nursing students. Nurse Education Today, 27, 192–202. doi:10.1016/j.nedt.2006.04.007 [CrossRef]
  • Cluver, L., Fincham, D.S. & Seedat, S. (2009). Posttraumatic stress in AIDS-orphaned children exposed to high levels of trauma: The protective role of perceived social support. Journal of Traumatic Stress, 22, 106–112. doi:10.1002/jts.20396 [CrossRef]
  • Cluver, L.D., Gardner, F. & Operario, D. (2008). Effects of stigma on the mental health of adolescents orphaned by AIDS. Journal of Adolescent Health, 42, 410–417. doi:10.1016/j.jadohealth.2007.09.022 [CrossRef]
  • Colaizzi, P.F. (1978). Psychological research as a phenomenologist views it. In Valle, R.S. & King, M. (Eds.), Existential-phenomenological alternatives for psychology (pp. 48–71). New York: Oxford University Press.
  • Deacon, H. & Stephney, I. (2007). HIV/AIDS stigma and children: A literature review. Retrieved from the Human Sciences Research Council website: http://www.hsrcpress.ac.za/product.php?productid=2197
  • Delva, W. (2010, November21). How supportive is the social network of AIDS orphans and other orphaned children in Conakry and N’Zérékoré, Guinea?SACE-MA Quarterly. Retrieved from http://sacemaquarterly.com/aids/how-supportive-is-the-social-network-of-aids-orphans-and-other-orphaned-children-in-conakry-and-n%E2%80%99zerekore-guinea.html
  • Demmer, C. (2004). Loss and grief following the death of a patient with AIDS. Social Work/Maatskaplike Werk, 40, 294–315.
  • Duncan, N. & Van Niekerk, A. (2001). Investing in the young for a better future: A programme of intervention. In Seedat, M., Duncan, N. & Lasarus, S. (Eds.), Community psychology: Theory, method and practice (pp. 325–341). Johannesburg, South Africa: Oxford University Press.
  • Economic Commission for Africa. (2004). Impact of HIV/AIDS on gender, orphans and vulnerable children. Retrieved from http://www.uneca.org/chga/cameroon/cameroon_orphans.pdf
  • Erikson, E.H. (1987). The life cycle completed: A review. New York: Norton. (Original work published 1982)
  • Funkquist, A., Eriksson, B. & Muula, A.S. (2007). The vulnerability of orphans in Thyolo district, southern Malawi. Tanzania Health Research Bulletin, 9, 102–109.
  • Joint United Nations Programme on HIV/AIDS. (2010). UNAIDS report on the global AIDS epidemic 2010. Retrieved from http://www.unaids.org/globalreport/documents/20101123_GlobalReport_full_en.pdf
  • Moules, N.J., Simonson, K., Prins, M., Angus, P. & Bell, J.M. (2004). Making room for grief: Walking backwards and living forward. Nursing Inquiry, 11, 99–107. doi:10.1111/j.1440-1800.2004.00204.x [CrossRef]
  • Nhate, V., Ardnt, C., Barslund, M. & Van den Broek, K. (2005). Orphans and discrimination in Mozambique: An outlay equivalence analysis. Retrieved from the International Food Policy Research Institute website: http://www.ifpri.org/sites/default/files/publications/arndtetal2005.pdf
  • Onuoha, F.N., Munakata, T., Serumaga-Zake, P.A., Nyonyintono, R.M. & Bogere, S.M. (2009) Negative mental health factors in children orphaned by AIDS: Natural mentoring as a palliative care. AIDS and Behaviour, 13, 980–988. doi:10.1007/s10461-008-9459-0 [CrossRef]
  • Rosenblatt, P.C. (1995). Ethics of qualitative interviewing with grieving families. Death Studies, 19, 139–155. doi:10.1080/07481189508252721 [CrossRef]
  • Save the Children UK. (2007). Kinship care: Providing positive and safe care for children living away from home. Retrieved from the Child Rights Information Network website: http://www.crin.org/docs/kinship_care.pdf
  • Stutterheim, S.E., Pryor, J.B., Bos, A.E.R., Hoogendijk, R., Muris, P. & Schaalma, H.P. (2009). HIV-related stigma and psychological distress: The harmful effects of specific stigma manifestations in various social settings. AIDS, 23, 2353–2357. doi:10.1097/QAD.0b013e3283320dce [CrossRef]
  • Visser, M. (2004). Life or lunch, what do we choose? HIV/ AIDS in the workplace. Retrieved from the Learning Development Institute website: http://www.learndev.org/People/MurielVisser/HIV-Workplace.pdf
  • Wood, K., Chase, E. & Aggleton, P. (2006). “Telling the truth is the best thing”: Teenage orphans’ experiences of parental AIDS-related illness and bereavement in Zimbabwe. Social Science and Medicine, 63, 1923–1933. doi:10.1016/j.socscimed.2006.04.027 [CrossRef]
  • Yale School of Public Health, Center for Interdisciplinary Research on AIDS. (2007). HIV-related stigma and discrimination in Asia: A review of human development consequences. Retrieved from the UNDP Regional Centre in Colombo website: http://content.undp.org/go/cms-service/download/publication/?version=live&id=1661457

Thupayagale-Tshweneagae, G. & Mokomane, Z. (2012). Discrimination Against South African Adolescents Orphaned by AIDS. Journal of Psychosocial Nursing and Mental Health Services, 50(1), 26–31.

  1. Adolescents orphaned by AIDS are discriminated against by caregivers, peers, and teachers.

  2. Writing in the diaries served as a mental process and afforded participants some relief.

  3. Mental health providers should be involved in the placement of orphans with relatives/guardians.

Keypoints

Do you agree with this article? Disagree? Have a comment or questions?

Send an e-mail to the Journal at jpn@slackinc.com.

Disrupted by Disaster: Shared Experiences of Student Registered Nurse Anesthetists Affected by Hurricane Katrina

Hurricane Katrina, one of the most devastating natural disasters in the history of the United States, ravaged New Orleans on August 29, 2005. The storm closed college campuses in New Orleans for the rest of the fall semester and displaced more than 50,000 college students (Ladd, Marszalek, & Gill, 2006). The building that housed a New Orleans-based nurse anesthesia program received 1 to 2 feet of water (Smith, 2005); because of this damage, it became apparent that the education of the student registered nurse anesthetists (SRNAs) would be disrupted.

Disasters on college campuses are not unique. In the past 5 years, campus shootings and natural disasters have affected college campuses across the nation. Disaster literature on college students exists; however, no study has been conducted regarding SRNAs or any other advanced nurse practitioner (ANP) students and natural disasters.

Background

SRNAs are RNs who are enrolled as students in an accredited nurse anesthesia program and have at least 1 year of intensive care unit experience. Nurse anesthesia programs are housed in nursing schools, schools of allied health, medical schools, and other graduate schools. All programs offer at least a master’s degree in nursing or in nurse anesthesia. This New Orleans-based nurse anesthesia program, housed in the nursing school, lasts 32 months and upon satisfactory completion awards a master of nursing degree with a specialization in nurse anesthesia option. The nurse anesthesia program is a full-time graduate-level program, and students are classified as freshmen, junior-level, or senior-level (senior) students within the program. The senior SRNAs documented in this article had less than 9 months left in their training when the storm disrupted their education.

Within 1 month of the storm, classes resumed in Baton Rouge, which is 74 miles northwest from New Orleans. When classes resumed, all students were required to attend classes for 5 consecutive days to “make up” missed classroom time because of Hurricane Katrina. After this initial week, classes were held on a weekly basis, and distance-learning technologies were implemented to decrease the driving requirements of the students who were attending clinical rotations outside of the Baton Rouge area. The use of distance learning technology allowed the students to synchronously attend class using their computers. This format allowed faculty members and students to sign into a specified cyber classroom; the faculty member was able to view a list of all participants who were signed in. The students were able to listen to the faculty member lecture while viewing the lecture material (i.e., Microsoft® PowerPoint®) being presented and were able to participate in classroom discussion by typing comments viewable to the faculty member and other students.

Method

This study was a focused ethnography using group interviews to determine: (a) the shared experience of SRNAs whose senior year was disrupted by Hurricane Katrina, and (b) the psychosocial impact Hurricane Katrina had on these SRNAs. The protocol was approved by the applicable Institutional Review Boards, and appropriate consents were obtained from all participants.

Focused ethnography describes a specific aspect of a culture and is generally conducted by someone familiar with the culture; therefore, fieldwork may not be warranted (Knoblauch, 2005; LeCompte & Schensul, 1999). Focused ethnography differs from traditional ethnography in that the latter includes extensive fieldwork (immersion of the investigator into the culture being investigated) that lasts from months to years. The investigator was familiar with all of the SRNAs whose senior year was disrupted by Hurricane Katrina, and fieldwork was not feasible for this study because the event (Hurricane Katrina) had passed. Culture can be described as a “persistent group pattern of behaviors, beliefs, norms, and attitudes” (LeCompte & Schensul, 1999, p. 21). The culture in this study was a group of senior-level SRNAs who were affected by a natural disaster. In an appropriately conducted focused ethnography, the relatively small sample is offset by the in-depth information provided about the phenomenon under study (Creswell & Plano Clark, 2007).

Sample

A convenience sample of 10 participants representing former SRNAs whose senior year was disrupted by Hurricane Katrina participated in one of three focus groups. Thirty-five senior-level students were continuously enrolled in the nurse anesthesia program for at least 22 months on August 29, 2005. The investigator (M.G.-E.) personally knew all of the students and was able to contact 20 of them via e-mail to invite them to participate in the study. The investigator was unable to contact the other 15 former students because they had relocated after the storm and did not provide contact information to either the investigator, the school, or their former classmates at the time of this investigation. Prior to the focus group interview, the participants were asked to complete a demographic survey, and the results were analyzed using SPSS version 13.0.

Ages of the participants during Hurricane Katrina ranged from 29 to 48, with the majority age range of 30 to 40. Five participants were women; 7 were Caucasian, 1 was African American, 1 was Asian, and 1 was Native American. Four reported being married, 3 reported being single, 2 reported being divorced, and 1 did not report a marital status at the time of Hurricane Katrina. Most of the participants had experienced more than 10 hurricanes, and all but one reported that they evacuated for Hurricane Katrina. No one lost family members, although 3 participants lost pets due to Hurricane Katrina. The reported property damage from Hurricane Katrina ranged from minimal to total loss of home and belongings.

Data Collection and Analysis

Three focus groups were interviewed. Two of the focus groups consisted of 3 people and one focus group consisted of 4 people. Many investigators believe the ideal focus group consists of 8 to 10 participants. Due to the number of people willing to participate in this study and their work schedules, smaller focus groups were used. The focus group interviews took place around a conference table in a quiet room with a co-facilitator, an experienced focus group researcher, who recorded notes and the participants’ nonverbal cues. The co-facilitator was introduced to the participants, and her role was explained to them.

To facilitate the interviews, the investigator used an interview guide consisting of a predetermined set of semi-structured questions, follow-up questions, and probes based on the Lazarus and Folkman (1984) stress, appraisal, and coping model. The interviews, which lasted between 45 and 60 minutes, were audiorecorded. When the interviews were completed, the participants were given the contact information of an experienced disaster counselor who had agreed to provide counseling if needed. The audiorecordings of the interviews were transcribed verbatim, and the investigator checked them for accuracy by reading the transcripts while listening to the audiorecordings. The investigator analyzed the resulting transcripts for codes, patterns, and emerging themes using NVivo8 software.

Results

The purpose of this study was to describe the shared experiences of SRNAs whose senior year was disrupted by Hurricane Katrina, examine the psychosocial impact Hurricane Katrina had on them, and analyze emerging themes based on their focus group interviews. Three major themes emerged from more than 70 pages of transcripts and notes from the co-facilitator and investigator. These themes were Seriousness of Urgency, Managing Uncertainty, and Stability Equaled Relief.

Seriousness of Urgency

The participants expressed a sense of urgency regarding the evacuation from and the impact Hurricane Katrina had on New Orleans. All but one participant evacuated for the storm, although several did not initially plan to evacuate. Some participants were urged by their family members to leave New Orleans. One participant stated, “My dad never did leave either [for prior hurricanes], but even he was in Houston saying, ‘You better get out of there.’” Another participant recalled, “You know, I wasn’t going to leave because we never leave, and my mom left, which was like, oh, she never leaves either.” When the mayor of New Orleans called for a mandatory evacuation, some participants realized the seriousness surrounding the storm. One participant shared:

Kind of hit home when he made that announcement. Because before that we were like, oh, it’s another hurricane, we’ll be alright. Then, you know, on TV here he is, oh, this is definitely serious…. He started doing all these scenarios that could happen, like this could be the worst storm in decades.

The seriousness of the storm did not end with the evacuation. Several participants remembered watching television coverage of the city in the aftermath of Hurricane Katrina and expressed disbelief at what was happening. One participant stated, “I had the computer and I was streaming information and we started seeing all the things that were happening [in the city] as the day went on…. We were all just kind of like, we can’t believe we can’t go home.” Another recalled, “When I started seeing the television with the water everywhere and all these people like at the airport and everything, I was like, oh my God, you know.”

Managing Uncertainty

The participants shared expressions of uncertainty regarding resumption of classes, graduating on time, returning to clinical rotations, status of family and pets, and damage to their property. They expressed great anxiety regarding the status of the nurse anesthesia program and whether classes would resume or if they would be able to complete their program of study and graduate. The participants of one focus group agreed with their colleague who stated:

It was a little bit chaotic, I guess, because without hearing anything from the program, there was a lot of uncertainty…if we were going to graduate on time, if we were going to graduate at all because, we had no idea what was really going in New Orleans, if the nursing school was still there.

One participant in a different focus group stated:

I think that would have been like the straw that broke the camel’s back because we were all just busting our butts to try and get done and to be told, Oh, you’re not going to graduate on time, that would have been devastating for a lot of people.

The rest of the participants in this particular focus group nodded their heads in agreement with this statement.

Several participants sought employment as RNs to support themselves while waiting to hear about resumption of classes. One person noted, “I figured the best thing to do was for me to get a job and start making some money and then just trying to get back in touch with everybody and figuring out where everybody was.”

Uncertainty existed regarding clinical assignments. Students were assigned to rotate in clinical sites in New Orleans as well as other sites around the state of Louisiana and a few sites in Mississippi, Tennessee, and Texas. Communication was poor after the storm, and several of the clinical sites were damaged. The participants stated they were unsure where to report for clinical assignments after Hurricane Katrina and before classes resumed. This uncertainty was exacerbated by faculty members’ inability to communicate with the students initially after the storm. A few participants noted that they were contacted by the program director and told to go to their assigned clinical sites if at all possible. Eventually all students were contacted by the program director and advised to view the school’s emergency website and their school e-mail accounts for information pertaining to the nurse anesthesia program and for communication with the faculty members. A few participants recalled reporting to a clinical site only to be told they were not needed because the site was using displaced certified registered nurse anesthetists (CRNAs). One participant reported that the site refused to let her complete her clinical assignment:

I showed up at [the hospital] I think the Friday morning after the hurricane, and the CRNAs over there told me that with the…not knowing anything about what the status of the nursing school was, that with regard to liability and stuff…I wasn’t protected, so they pretty much said, “You can’t function here as an SRNA because without us knowing what status the school is in, you’ve got no protection whatsoever,” and it was like a liability thing for them to let me work [train] there.

Travel and housing were also areas of concern and uncertainty. Some participants reported being thankful that housing was provided by some of the clinical sites, while others reported that they had a difficult time finding housing near their sites. One person said a CRNA preceptor rented her a pool house 30 minutes from the clinical site, and another stated that she stayed with a classmate’s family who lived near her site. The participants mentioned they had difficulty finding fuel for their vehicles and had to carry full gasoline cans with them when they traveled to clinical sites and to school, because many gas stations were damaged and closed after the storm.

The participants shared further uncertainty regarding the status of their family members, pets, and homes. Communication was sporadic, as several participants noted that “there was no communication with the outside world besides texting.” One participant recalled, “You know, we lost our houses. And you can’t get in touch with your family members because everybody’s trying to call on the phone.” Another participant revealed that “just [the] anxiety of the unknown, how are your loved ones, how are your animals, what am I going to do about money? What am I gonna do about housing? It was ongoing and, you know?” One person left her cats at home prior to evacuating because she thought she would be able to return within a few days to take care of them: “I got stressed about that. Oh God, you get visions in your head of your cats drowning and starving to death.”

The participants shared their concerns about the rumors surrounding lawlessness in the city and worried for their personal safety when they returned to their homes to assess storm damage. One participant stated, “I bought my handgun and a shotgun in the next couple of weeks and so it was just…feeling like I was having to fend for myself in…almost a primal way, you know, worried about my personal safety.” A few participants “snuck” back into the city to check on their homes and pets prior to the mayor officially allowing citizens to return to New Orleans. Those who illegally re-entered the city recalled being frightened because of the lawlessness, yet the city was relatively “peaceful and quiet and there were no birds chirping.” They also noted trees and power lines were down around the city and that the grass was gray, brown, and crunchy.

Stability Equaled Relief

All of the students expressed relief regarding the resumption of classes after Hurricane Katrina and the ability to graduate on time. Within a month after the storm devastated New Orleans, classes resumed in Baton Rouge. During the regular semester, classes were held 1 day per week. After Hurricane Katrina, classes were held every day for the first 5 days and weekly thereafter. Face-to-face class attendance was mandatory during the first full week, but afterward the students were given the choice to attend class via distance technology or in person; most of the participants chose to attend class in person. A few participants who did use the distance technology expressed being grateful for the convenience of not having to search for gas and drive to campus to attend class. One participant pointed out that storm debris cluttered the highways, which made driving hazardous.

Some participants lost books, computers, professional attire, and anesthesia equipment due to Hurricane Katrina, of which they were able to purchase or borrow new items. They shared that manufacturers gave them scrubs, and one person even received a free pair of shoes to replace the ones she lost in the storm. Other participants stated that although they did not lose their books, computers, scrubs, and anesthesia equipment, they were unable to retrieve these items for several weeks following the storm because they were not allowed to return to their homes.

When asked about their thoughts with respect to the resumption of classes, relief and the return to stability were common responses from participants. One participant stated that “the fact that school started back up and we were allowed to get back into clinical, it gave me some sense that you were gonna be OK, that the school was intact, you were going to graduate eventually.” Another participant noted “immediate relief. We were all just rejoicing, so happy. Immediate relief. We were fine, let’s get on with it. It was something to hold onto.” Another participant recalled:

I was very glad we were going to resume because I think from my standpoint, it was more of a financial burden and was hoping that geez, I hope I don’t have to sit out another year to just keep borrowing more and more money. So that was a major concern of mine, so I was much relieved to hear that we were resuming classes and the way things planned out.

Another person’s response to the resumption of classes was, “But when we found that it was coming back, it’s just… oh, we were just relieved with thank goodness. So great relief. Ready to get back to something stable, yeah.”

The participants were asked about the first class after Hurricane Katrina when everyone was together in one room. Several quotes summarize the shared experiences expressed by the participants:

  • Oh, it was wonderful to-body. It was great to be able to just to hug everybody and make sure everybody was OK. And then, of course, you know, then you could actually hear everybody else’s stories and it was definitely… not only was an educational thing, but also just more of a social structure.
  • You realize everybody around OK, we made it through, you know. Because some people’s stories, just everybody [would] get really quiet and listen and then other people, of course, had funny things that happened and, you know, it’s just like, oh gosh, the same experience. So it was… that was very cathartic to be able to meet with everybody and visualize everybody and say, Oh my gosh, we’re all, we made it, we’re back…. You just wanted to blink your eyes and for it to be over with to come back to New Orleans.
  • I think that it was just a sense of relief because we were assured that the very first day that we were going to graduate on time, you know, so regardless of what sacrifices we were going to have to make because the program wasn’t able to function in New Orleans anymore, the timeline [of graduation] was not going to be disturbed at all.

Every participant expressed relief when they were told by the program director and the other anesthesia faculty members that they would graduate on time, in May 2006. One participant stated, “I felt really reassured by you guys saying, ‘You are going to graduate.’ And I think with [the program director]...I felt assured if anybody could get it done, she was going to make sure that we got out of there.” Other participants expressed gratitude that they were able to graduate on time. Some of them stated that they were concerned about finding jobs after graduation because many of the New Orleans hospitals were still closed in May 2006.

Psychosocial Impact of Hurricane Katrina

One aim of this study was to examine the psychosocial impact of Hurricane Katrina on the former SRNAs whose senior year was disrupted by the every disaster. All of the participants denied having any long-term psychosocial impact from Hurricane Katrina. Several participants mentioned short-term stress and anxiety related to experiencing Hurricane Katrina. Several revealed that the stress and anxiety were related to the uncertainty of being able to complete their education. Most described a short-term increase in alcohol consumption after the storm to decrease their stress. One person started smoking cigarettes as a result of the events surrounding the disaster.

The participants discussed the impact Hurricane Katrina had on their family members and other people more so than the impact it had on them. One participant stated:

I think that for me it was hard for me to allow myself to feel any kind of stress or anxiety because I knew that there were other people who were in a much worse place than I was. I mean, you know, people losing their houses and stuff. You know, the fact that somebody had broke into my apartment and stole a few things, I mean, it just kind of paled in comparison, you know, to the people who lost houses and lost family members and whatnot, and so I think that I…if there was anything going on with me, like, it got kind of like suppressed or repressed.

Several participants noted that older family members were more affected by Hurricane Katrina than the participants themselves were because the older people had to see “everything they built up just come apart.” The participants described themselves as cohesive and resilient. One participant mentioned that the first-year students in the nurse anesthesia program had a more difficult time than the seniors regarding their educational process: “God, if you were, you know, a freshman, that would have been so much more difficult. You know, and our class is really close and to see everybody, you know, once a week was so important, and not to have that, you know.” One participant mentioned losing everything and how that made her feel: “It was weird because I was so materialistic…. After you got over…losing everything, it was like a cleansing.” Another participant agreed with her by responding with “uh-huh.”

Discussion

This focused ethnography described the shared experiences of students whose senior year was disrupted by Hurricane Katrina as well as elucidated the psychosocial impact the storm had on them. This study was based on the stress, appraisal, and coping theory of Lazarus and Folkman (1984), which describes stress as a relationship between a person and the environment; in other words, a transactional process that emphasizes the individual’s analysis of the event, the individual’s cognitive appraisal of the importance of the event, and the individual’s determination of the response to the event, including available resources to cultivate the response (Matthieu & Ivanoff, 2006). For this study, the cultural environment of being a SRNA produced a template for the participants to frame their shared, stressful experiences. The Figure depicts the theoretical framework of the study.

The unexpected and urgent need to evacuate for a powerful hurricane; the graphic images on television that showed what was taking place in the city in the aftermath of the storm; the concern for the condition of their family members, pets, homes, and school; and the concern for personal safety were all shared stressors related to the events surrounding Hurricane Katrina. Most SRNAs appraised the hurricane as a potential serious threat and responded by urgently evacuating from the city. After the storm, they realized they were experiencing a crisis when they appraised a lack of communication with school officials and clinical preceptors, thereby causing concern regarding the status of the school and completion of their education. Lack of communication also led to shared uncertainty regarding the status of family members, pets, and homes. Coping measures that were shared among the SRNAs included anxiety, a temporary increase in alcohol consumption, seeking nursing jobs, and staying heavily focused on their education and pending graduation once classes resumed. As mentioned above, one participant purchased guns out of extreme concern for his personal safety. Many engaged in downward social comparison (“I was fortunate, we weren’t affected as much as other people”) and other forms of cognitive reframing (“It was like a cleansing”).

Very little research exists in reference to disasters and college campuses/students, although tragedies on campuses are not uncommon. McCarthy and Butler (2003) found that college students who were exposed to a tornado on campus experienced a progressive decline in anxiety, anger, and irritability over time. Their findings parallel those in this focused ethnography, where the participants experienced short-term anxiety that dissipated over time. Blanchard et al. (2004) surveyed college students on campuses in New York, Georgia, and North Dakota regarding the World Trade Center terrorist tragedy of September 11, 2001. They found widespread high levels of acute stress related to the tragedy. These findings are similar to those of this focused ethnography, in which the participants experienced high levels of stress and anxiety related to Hurricane Katrina and its aftermath. Cardenas, Williams, Wilson, Fanouraki, and Singh (2003) found that college students had an increased level of alcohol and substance abuse following the events of September 11, 2001. This is congruent with the findings of this focused ethnography, in which the participants responded to the events surrounding Hurricane Katrina with temporary increased alcohol consumption.

A number of limitations are associated with this study. First, the study took place 4 years after the storm, and memories may have changed over time. Another limitation is the study’s use of convenience sampling, and the results may not be transferable except to other SRNAs whose senior year is disrupted by a hurricane or other similar natural disaster. Finally, the study may have been biased toward those who wished to tell their stories.

Implications for Practice and Education

An implication of this study for SRNA and other student advanced nurse practitioner education includes developing plans, policies, and procedures for the relocation and resumption of nursing education after a disaster. This study highlights the necessity of developing policies for assuring ongoing communication between faculty and students in the immediate aftermath of a disaster. An implication for practice consists of developing policies regarding clinical assignments during disasters, educating the clinical preceptors of the policies, and communicating with the clinical sites that the educational program is open and students’ liability insurance is in effect. An implication for future research involves the examination of the reactions and responses of SRNAs and CRNAs in the global wake of natural disasters, such as tornadoes, earthquakes, volcanic eruptions, and flooding, and their impact on all levels of SRNAs’ and CRNAs’ physical and emotional aftermath.

On the basis of the findings of this study and others regarding college students and disasters, students’ psychosocial needs during—and in the immediate aftermath of the event—should be supported. Effective communication between the program faculty and students is essential to support the students’ psychosocial needs. Psychosocial support can be in the form of counseling referrals prior to the students returning to class and formalized crisis debriefing when the students return to class. Other forms of psychosocial support include individual assessments for anxiety and individual or group counseling.

Conclusion

The SRNAs shared a sense of urgency and gravity surrounding Hurricane Katrina, the evacuation process, and their sense of personal safety. They were uncertain whether they would be able to complete their education and graduate on time. Once classes resumed, they shared relief that their education would continue and that they would indeed graduate on schedule. This was the first study to systematically examine and document SRNAs’ reactions to a natural disaster and the impact the disaster had on their stress appraisal and coping mechanisms. This study can inform educators of the impact a natural disaster may have on graduate nursing students and the critical importance of having disaster policies in place. Disaster policies may include communication between the school faculty, students, and clinical preceptors after a disaster; education of students after a disaster; and psychosocial support of students following a disaster.

References

  • Blanchard, E.B., Kuhn, E., Rowell, D.L., Hickling, E.J., Wittrock, D., Rogers, R.L. & Steckler, D.C.,… (2004). Studies of the vicarious traumatization of college students by the September 11th attacks: Effects of proximity, exposure and connectedness. Behaviour Research and Therapy, 42, 191–205. doi:10.1016/S0005-7967(03)00118-9 [CrossRef]
  • Cardenas, J., Williams, K., Wilson, J.P., Fanouraki, G. & Singh, A. (2003). PTSD, major depressive symptoms, and substance abuse following September 11, 2001, in a midwestern university population. International Journal of Emergency Mental Health, 5, 15–28.
  • Creswell, J.W. & Plano Clark, V.L. (2007). Designing and conducting mixed methods research. Thousand Oaks, CA: Sage.
  • Knoblauch, H. (2005). Focused ethnography. Forum: Qualitative Social Research, 6(3). Retrieved from http://www.qualitative-research.net/fqs-texte/3-05/05-3-44-e.htm
  • Ladd, A.E., Marszalek, J. & Gill, D.A. (2006). The other diaspora: New Orleans student evacuation impacts and responses surrounding Hurricane Katrina. Paper presented at the annual meeting of the Southern Sociological Society. , New Orleans. .
  • Lazarus, R.S. & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
  • LeCompte, M.D. & Schensul, J.J. (1999). Designing and conducting ethnographic research. Walnut Creek, CA: Sage.
  • Matthieu, M.M. & Ivanoff, A. (2006). Using stress, appraisal, and coping theories in clinical practice: Assessments of coping strategies after disasters. Brief Treatment and Crisis Intervention, 6, 337–348. doi:10.1093/brief-treatment/mhl009 [CrossRef]
  • McCarthy, M.A. & Butler, L. (2003). Responding to traumatic events on college campuses: A case study and assessment of student postdisaster anxiety. Journal of College Counseling, 6, 90–96. doi:10.1002/j.2161-1882.2003.tb00230.x [CrossRef]
  • Smith, R. (2005, September30). Hurricane Katrina recovery—Update #1. Retrieved from the Louisiana State University Health Sciences Center website: http://www.lsuhsc.edu/biweekly/update_20050930.aspx

Geisz-Everson, M.A., Bennett, M.J., Dodd-McCue, D. & Biddle, C. (2012). Disrupted by Disaster: Shared Experiences of Student Registered Nurse Anesthetists Affected by Hurricane Katrina. Journal of Psychosocial Nursing and Mental Health Services, 50(1), 32–38.

  1. Disaster, whether man-made or natural, can strike any college campus.

  2. Many college students experience temporary psychosocial alterations following disasters.

  3. Effective communication between faculty and students is essential to support students’ psychosocial needs after a disaster.

  4. Clear policies and procedures regarding resumption of classes after a disaster is essential for all college programs.

Keypoints

Do you agree with this article? Disagree? Have a comment or questions?

Send an e-mail to the Journal at jpn@slackinc.com.

Revising a Medication Education Program on an Inpatient Child and Adolescent Psychiatric Unit

Psychotropic medications are frequently used in the treatment of mental health disorders in children and adolescents. Promoting medication adherence through education is an important responsibility of mental health nurses, as adherence to medications during the child and adolescent years can improve overall treatment effectiveness and health (Worley & McGuinness, 2010a). The “how to” of engaging children and adolescents and their families in medication education can be challenging. The purpose of this article is to describe an initiative to revitalize the medication education provided to children and adolescents and their families on an inpatient mental health unit to increase knowledge, adherence, and satisfaction regarding their medication regimens.

Background

Psychotropic medication adherence in youth is a well-documented problem. It has been documented that adherence rates for children taking psychotropic medications range anywhere from 34% to 89% (Hamrin, McCarthy, & Tyson, 2010). The consequences of nonadherence can be enormous and may include low remission rates, high relapse rates, unnecessary disease progression, increased risk of substance abuse, social issues, decreased quality of life, reduced functional abilities, and death (Hardeman & Narasimhan, 2010; Worley & McGuinness, 2010a).

Educating patients regarding prescribed medication is a helpful way to contribute to medication adherence. Education may also be associated with an increase in satisfaction of psychiatric services and a decrease in relapse (Swadi, Bobier, Price, & Craig, 2010). Education provides the patient with a sense of empowerment, improves the sense of alliance between the health care provider and the patient, and assists in the process of obtaining the child’s assent. Obtaining assent is a possible way to minimize nonadherence, especially among adolescents (Costea, Barreto, & Burns, 2008; Kavanagh, Duncan-MacConnell, Greenwood, Trivedi, & Wykes, 2003).

It is important for nurses to know what to include when providing medication education to facilitate accomplishing the goal of increased medication adherence. The following information is important to include when educating on medicine: the goal of medication therapy, target symptoms, potential side effects, consequences of nonadherence, how long the medication will take to work, how and when the medication should be taken, where the medication should be stored, and blood levels that may be needed to monitor efficacy and toxicity (Howland, 2009; Worley & McGuinness, 2010b).

Knowing how to present key information regarding medications is also essential. A report from the Joanna Briggs Institute (2007) stated that an easy-to-read fact sheet followed by discussion was more beneficial for the patient than the use of a fact sheet alone. Clarity, conciseness, and repetition were found to be important regarding medication education and mental health (Hardeman & Narasimhan, 2010; Joanna Briggs Institute, 2007).

When educating teenagers, facts should be straightforward, easy to retain, reinforced with illustration and repetition, and followed with a requirement for the learner to repeat back what was learned (Apa-Hall, Schwartz-Bloom, & McConnell, 2008). An inpatient adolescent psychiatric unit in Australia reported that using a variety of teaching tools is helpful in providing psychoeducation to meet diverse learning needs of the patients. Teaching tools this unit used included verbal interactions, videos, whiteboards, games, and written information (Swadi et al., 2010).

Education in a Group Setting

Medication education in a group setting is an efficient way to deliver information. Recent findings regarding the use of medication education groups, although sparse, indicate positive results. Kavanagh et al. (2003) reported on the results of an exploratory study examining educating acute adult psychiatric inpatients on medications in a group setting. The results showed an improvement in knowledge and insight, but no effect on adherence. The staff observed that the patients asked more questions about medications and had on overall increased interest in learning about medication (Kavanagh et al., 2003). A report from another in-patient psychiatric unit stated that education programs should be structured and systematic (Hätönen, Suhonene, Warro, Pitkänen, & Välimäki, 2010).

Tankel (2001) reported on a medication education group and game approach and stated that interactive educational activities can be particularly helpful for group settings to promote learner engagement and participation. Adding a game could provide an enjoyable learning environment that reinforces learning (Tankel, 2001). Billings and Halstead (2009) asserted that games can improve learning retention, motivate and engage learners, promote interpersonal learning, and provide immediate feedback.

Involving family in the education process is also important. Hardeman and Narasimhan (2010) reported that family involvement can decrease relapse and support medication adherence. Using a multifamily group approach to education is an intervention that may also decrease relapse, promote recovery, and increase knowledge level. It has been shown to be more effective in decreasing relapse and improving recovery than individual family work (Mullen, Murray, & Happell, 2002).

Identification of a Need

Working as a nurse on an acute child and adolescent inpatient psychiatric unit presents many challenges. Short hospital stays, high nurse-to-patient ratios, and floating between units can limit time with patients and decrease the ability to create patient-provider relationships. These issues may impair nurses’ ability to provide adequate medication education to patients; therefore, mental health nurses are challenged to find creative ways to meet the educational needs of patients. Nurses may ask themselves: What do the patients need to know about taking medications? Am I using evidence-based techniques when educating my patients? Are my patients receiving adequate information regarding their medication? These factors were all taken into consideration as the nursing staff on our inpatient unit assessed the medication education provided to our patients and their families.

Our inpatient mental health unit is composed of an 18-bed hall for adolescents (ages 12 to 18) and a 16-bed hall for children (12 and younger) located within a hospital-affiliated mental health inpatient facility. The average length of stay is 3 to 6 days. Patients are admitted into the hospital with diagnoses such as bipolar, major depression, anxiety, substance abuse, and psychotic disorders. A psychiatrist assesses each patient on a daily basis for medication management and review. Common medications prescribed include antidepressant, anxiolytic, antipsychotic, and anticonvulsant agents. Some patients who have never taken psychotropic medications are prescribed medications while in the hospital. In other cases, the inpatient stay is often a time to modify a patient’s medication regimen. In either case, medication education is crucial for patients and their families with regard to the purpose, side effects, and safety precautions of these psychotropic medications.

As in most facilities, efforts to improve the quality and outcomes of care are recognized as essential components of health care delivery. Therefore, process improvement projects that include staff member participation are initiated when a need is assessed. The focus of one particular project on our unit was medication education. This team included two staff nurses, the unit manager, the unit social worker, and the care coordination specialist (C.M.E.).

The need to revise and potentially improve our medication education on the children and adolescent unit was rooted in three assessment indicators. The first indicator was based on an item on our Press Ganey™ survey. Every family is given the opportunity to fill out this Likert-style satisfaction survey, which is used by 50% of hospitals in the nation to improve performance (Press Ganey, 2011). One item on the survey addresses how well nurses provide information regarding medication. Many patients and families on our unit do not respond favorably to this item, reflecting a need to improve the medication education process. A second factor regarding the need for improved education is that many of our patients, particularly on the adolescent unit, come into the hospital admitting that they have not been adherent to their medication schedule. Some of these patients have been previously hospitalized in our facility or one similar to ours. Finally, the third factor was the wide variability regarding when numerous nursing staff provide education. We decided it would be important to streamline the process of providing medication education to ensure our patients were receiving appropriate information. Nurses often voiced a need for additional resources when providing education to patients and family members.

Current Medication Education

The team then assessed the current medication program to plan for revisions. The current medication education program consisted of weekly nurse-run medication education groups provided to both the children and adolescents. Topics in these groups include name, dosage, and purpose of medication; time medication should be taken; safety precautions when taking medications; side effects; and medication interactions. Teaching strategies used by the group leader included fill-in-the-blank worksheets and a “medication ball game,” where the patients take turns reading and answering questions about medication that is written on the ball. This group is led by the care coordination specialist, who has 7 years of psychiatric nurse experience and is board certified in psychiatric and mental health nursing.

Also discussed was a previously existing medication education group program for parents led by one of the psychiatrists who specialized in child/ adolescent mental health. In the past, these sessions were generally well attended and appreciated by families. However, the program was abandoned several years ago due to the psychiatrist’s change in responsibilities and time constraints. A review of these interventions for the existing program was conducted as a foundation to deciding on revisions and/or additions for this new program initiative.

Planning for the Program Initiative

Based on our examination and discussions of the existing medication education program, the team identified the following goals for providing medication to our patients and their families:

  • Improve the quality of medication education provided to both patients and their families through the use of a variety of evidence-based teaching strategies.
  • Increase patient and parent engagement in learning.
  • Involve parents in medication education by providing a weekly session for parents/guardians.
  • Improve respondent feedback on the Press Ganey survey item regarding nurse-provided medication education.

Because we have such a short length of time with our patients, who have diverse educational needs, we wanted to provide additional evidence-based interventions to improve our medication education. When reviewing the literature, we decided that adding a game, providing fact sheets, and creating a medication education group for families were evidence-based interventions that could help us meet our goals.

Revised Program Contents

In keeping with the goals of the program to empower individuals through knowledge, the primary educator (care coordination specialist) of this program believed it was important to use humanism as an underlying educational framework during the revision, implementation, and evaluation. A primary focus of this theory is helping individuals learn how to attain knowledge and how to ask questions.

The nurse-run medication education groups for the children and adolescents continued to be provided as described previously. The children’s group meets for 30 minutes one to two times per week. No additional interventions were added to the children’s unit group. The adolescent group meets for 1 hour two times per week. The first group session for the adolescent patients consists of the fill-in-the-blank worksheet and “medication ball game,” as mentioned previously. To increase the engagement of the adolescent participants, we created a quiz show-type game that is played during the second group session. The game’s categories include: My Meds, True or False, Classes of Meds, Abuse, and Miscellaneous. The questions included in the game are a review of the material covered in the medication group. Sample questions from this game include:

  • Pick one of your medications and state two potential side effects.
  • Should you take your medication with food?
  • What class of medications can take up to 4 to 6 weeks to be at full therapeutic effect?
  • Name three potential complications that can happen when alcohol is mixed with medications.

Another strategy we used to evaluate knowledge attainment was to ask the patients at the end of the medication group, “What is one thing you learned in this group?” Asking the patients to paraphrase what they have learned is an important teaching strategy when working with children (Apa-Hall et al., 2008).

Medication education sheets containing bullet points of commonly prescribed psychotropic medications for patients and their parents were created and distributed. These were created to ensure patients and their families were receiving adequate information regarding their medication. The handouts provided essential information on a particular medication, including purpose and benefit of the medication, time of activation, and side effects. The handouts were used during the medication groups and were accessible to the unit nurses and psychiatric technicians for distribution to patients and their families. An example of a handout is provided in the Figure.

A final part of our team’s plan was to develop a nurse-run parent medication education session. This group was also provided by the care coordination specialist. The group met for 1 hour every Monday evening. A Microsoft® PowerPoint® presentation was created and then presented during each session. The topics of the presentation included signs and symptoms of common psychiatric illnesses in children and adolescents, classes of psychotropic medications, side effects, and frequently asked questions regarding psychotropic medications. A discussion and question-and-answer period followed each presentation.

Every parent/guardian who had a child admitted to the child or adolescent unit at the time of the group was invited to attend the parent medication group. On their child’s admission to the unit, parents/guardians were given a handout inviting them to the group. Flyers were also posted on the unit. Unit nurses, psychiatric technicians, social workers, and family therapists were educated on the purpose of the group and were asked to encourage and stress to parents the importance and potential benefits of their attendance.

Program Evaluation

Medication Education Groups for Adolescent Patients

The nurse-run medication education groups for adolescents are mandatory, and therefore are well attended. A challenge of these groups is attaining and maintaining enthusiasm and engagement, as many adolescents find the topic of medication “boring.” Adding the quiz show-type game to these groups sessions aided in the goal of increasing active participation and enthusiasm. At the end of the group session, the adolescents are each provided an opportunity to share thoughts on the group session. The educator asks the patients questions such as “Do you think this is a good way to learn about medications?” and “Do you have any suggestions on how to improve this group?” Comments at the conclusion of the sessions were positive. Adolescent comments included, “This was a really fun way to learn about medications!” and “I learned things I didn’t know.” In addition, ending the group with having the patients identify one thing they learned reinforced what they learned and assured the nurse that the patients did retain the information.

Medication Education Handouts

In regard to the education handouts, the primary educator of this program (care coordination specialist) asked nurses on the unit the following questions:

  • Are you using the handouts?
  • What feedback have parents given you regarding the handouts?

These questions were asked via short face-to-face interviews with six RNs who worked primarily on the children and adolescent unit. Nursing staff voiced gratitude for the accessible and reader-friendly medication handouts. The nurses believed they aided in providing consistent information regarding medication. However, nurses reported that additional medication sheets are needed, as we currently have handouts for only 22 medications. Also, nurses reported that they sometimes “forgot” the handouts were available and would welcome continued encouragement and reminders to make these available to patients and parents. When the handouts were used, the nurses reported hearing positive comments from families who appreciated the simplified, need-to-know information provided. In the future, it may be helpful to place copies of the handouts in areas accessible to parents to increase availability. Another suggestion is to give the appropriate handout to the parents when consent for medication administration is obtained or along with discharge instructions when the patient is released from the hospital.

Medication Education Group for Parents

Attendance at the parent medication education group has been disappointing. The sessions have been conducted weekly over the course of 15 weeks. A total of 9 families have attended, with one family attending two times. Total number of families that could have attended is approximately 245. One parent from each family generally attended the session. The majority of the parents have been from the children’s unit (8 of 9) and the child (patient) has not attended the group. Each attendant was given a handout of the PowerPoint presentation, followed by an informal discussion of medication education. The discussion was tailored to the needs of the families represented. Parents were engaged, and questions were encouraged by the group leader.

Each family that comes to the group is given a Likert-style evaluation form with responses ranging from 1 (strongly disagree) to 5 (strongly agree). The evaluation form asked for feedback on the following statements:

  • The format of this class suited my needs and kept my interest.
  • This class was well organized.
  • The knowledge and delivery style of the presenter enhanced my learning.
  • Overall, I would rate this program as beneficial to me.

Eight evaluation forms were returned. Seven of the eight evaluation forms reported strongly agree on all four statements, and one form reported agree on all four statements. Additional comments such as “Thanks for taking the time to do this” and “I always wanted to know what my son’s medication was for and how it worked” were stated by those who took advantage of the medication education session. Another outcome from this group was that participants were able to share experiences, concerns, and frustrations with one another, which provided them with additional support and a feeling that they were not alone in having a child with a mental illness.

It is not clear why the parent group has been poorly attended. Based on information from staff members and conversations with several families who did not attend the educational sessions, it is concluded that possible reasons for nonattendance included transportation barriers, time constraints, bad weather, lack of understanding of the importance of medication education, and disinterest. As such, the process improvement team discussed ideas to improve attendance by providing incentives (i.e., food, gas gift cards, or prizes), offering the group on a different day or at multiple times during the week, changing the format of the group to an informal question-and-answer session, involving a psychiatrist, and videotaping sessions and having them available during visiting hours.

Implications and Conclusion

Providing medication education to patients is an important aspect of the nursing role. Having successful interventions in place may help promote medication adherence in our patient population, as medication adherence is an essential part of mental health care.

Providing such education to adolescent and children patients and families on an inpatient psychiatric unit can be challenging. Creativity, energy, and perseverance are important qualities in providing this type of education. Equally challenging are finding ways to revise and revitalize existing programs to promote better patient and family education. This article describes one unit’s attempt to improve the medication education provided to patients and their families. Interventions included adding a game during one of the adolescent medication education groups, creating medication education handouts, and developing and implementing a medication education group for parents/guardians. The adolescent patients enjoyed the group activities and were able to identify one thing they learned. The medication handouts were well received and appreciated, although not always used. The parents/guardians who participated in the medication education group gave positive feedback.

Although we did not find improvement in our Press Ganey satisfaction scores, we were not able to segregate the responses of those who participated in the parent sessions from those who did not; therefore, these findings are not reliable. In the future, it is recommended that evaluation of this medication education program be more specific to the program rather than heavily relying on the results obtained from the Press Ganey survey. In conclusion, we believe our initiatives improved patient education and are an initial step in increasing patient and family engagement in learning.

References

  • Apa-Hall, P., Schwartz-Bloom, R.D. & McConnell, E.S. (2008). The current state of teenage drug abuse: Trend toward prescription drugs [Supplement]. Journal of School Nursing. Retrieved from http://www.nasn.org/Portals/0/resources/pd_toolkit_nurses_supplement.pdf
  • Billings, D.M. & Halstead, J.A. (2009). Teaching in nursing: A guide for faculty (3rd ed.). St. Louis: Saunders Elsevier.
  • Costea, G.O., Barreto, S. & Burns, M.L. (2008). Talking with children about medication: From ethics to patient education. The Brown University Child and Adolescent Behavior Letter, 24(12), 1–2. doi:10.1002/cbl.20081 [CrossRef]
  • Hamrin, V., McCarthy, E.M. & Tyson, V. (2010). Pediatric psychotropic medication initiation and adherence: A literature review based on social exchange theory. Journal of Child and Adolescent Psychiatric Nursing, 23, 151–172. doi:10.1111/j.1744-6171.2010.00237.x [CrossRef]
  • Hardeman, S.M. & Narasimhan, M. (2010). Adherence according to Mary Poppins: Strategies to make the medicine go down. Perspectives in Psychiatric Care, 46(1), 3–13. doi:10.1111/j.1744-6163.2009.00233.x [CrossRef]
  • Hätönen, H., Suhonene, R., Warro, H., Pitkänen, A. & Välimäki, M. (2010). Patients’ perceptions of patient education on psychiatric inpatient wards: A qualitative study. Journal of Psychiatric and Mental Health Nursing, 17, 335–341. doi:10.1111/j.1365-2850.2009.01530.x [CrossRef]
  • Howland, R.H. (2009). What should patients be told about their medications?Journal of Psychosocial Nursing and Mental Health Services, 47(2), 17–20. doi:10.3928/02793695-20090201-05 [CrossRef]
  • Joanna Briggs Institute. (2007). Educational interventions for patients receiving psychotropic medication. Nursing Standard, 22(12), 40–44.
  • Kavanagh, K., Duncan-MacConnell, D., Greenwood, K., Trivedi, P. & Wykes, T. (2003). Educating acute inpatients about their medication: Is it worth it? An exploratory study of group education for patients in a psychiatric intensive care unit. Journal of Mental Health, 12(1), 71–80. doi:10.1080/09638230021000058319 [CrossRef]
  • Mullen, A., Murray, L. & Happell, B. (2002). Multiple family group interventions in first episode psychosis: Enhancing knowledge and understanding. International Journal of Mental Health Nursing, 11, 225–232. doi:10.1046/j.1440-0979.2002.00253.x [CrossRef]
  • Press Ganey. (2011). About us. Retrieved from http://www.pressganey.com/aboutUs.aspx
  • Swadi, H., Bobier, C., Price, L. & Craig, B. (2010). Lessons from an audit of psycho-education at an older adolescent inpatient unit. Australasian Psychiatry, 18, 53–56. doi:10.3109/10398560902721580 [CrossRef]
  • Tankel, K. (2001). Therapeutic interactions in a medication education group using the psychopharmacology RACE. Journal of Psychosocial Nursing and Mental Health Services, 39(6), 22–30.
  • Worley, J. & McGuinness, T.M. (2010a). Promoting adherence to psychotropic medication for youth—Part 1. Journal of Psychosocial Nursing and Mental Health Services, 48(10), 19–22. doi:10.3928/02793695-20100831-03 [CrossRef]
  • Worley, J. & McGuinness, T.M. (2010b). Promoting adherence to psychotropic medication for youth—Part 2. Journal of Psychosocial Nursing and Mental Health Services, 48(12), 22–26. doi:10.3928/02793695-20101102-01 [CrossRef]

Eisenmann, C.M. (2012). Revising a Medication Education Program on an Inpatient Child and Adolescent Psychiatric Unit. Journal of Psychosocial Nursing and Mental Health Services, 50(1), 41–47.

  1. Medication education is an important tool for nurses to use in promoting medication adherence.

  2. Teenagers appreciate creativity, such as games, in regard to medication education.

  3. When medication handouts were used, nurses reported that they heard positive comments from families who appreciated the simplified, need-to-know information provided.

Keypoints

Do you agree with this article? Disagree? Have a comment or questions?

Send an e-mail to the Journal at jpn@slackinc.com.

CNE Quiz

How to Obtain Contact Hours by Reading This Issue

Instructions

4.0 contact hours will be awarded by Vindico Medical Education upon successful completion of the posttest and evaluation. To obtain contact hours:

  1. Read the following articles carefully, noting the tables and other illustrative materials, which are provided to enhance your knowledge and understanding of the content:

    • Discrimination Against South African Adolescents Orphaned by AIDSGloria Thupayagale-Tshweneagae, RN, MNS, DTech; and Zitha Mokomane, PhD, on pages 26–31.
    • Disrupted by Disaster: Shared Experiences of Student Registered Nurse Anesthetists Affected by Hurricane KatrinaMarjorie A. Geisz-Everson, CRNA, PhD; Marsha J. Bennett, DNS, APRN, ACRN; Diane Dodd-McCue, DBA; and Chuck Biddle, CRNA, PhD, on pages 32–38.
    • Revising a Medication Education Program on an Inpatient Child and Adolescent Psychiatric UnitCarmen M. Eisenmann, MSN, RN-BC, on pages 41–47.

  2. Read each question and record your answer on the CNE Registration Form provided.

  3. Complete all sections of the CNE Registration Form, including indicating the total time spent on the activity (reading articles and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

  4. Forward the completed form with your check or money order, drawn on a US bank, for $20 (USD) made out to JPN-CNE.

CNE Registration Forms must be received no later than January 31, 2014.

Contact Hours

Vindico Medical Education is an approved provider of continuing nursing education by the New Jersey State Nurses Association, an accredited approver, by the American Nurses Credentialing Center’s Commission on Accreditation. P188-6/09-12. This activity is co-provided by Vindico Medical Education and the Journal of Psychosocial Nursing.

This is a Learner-Paced Program. Answers to the posttest will be graded, and you will be advised that you have passed or failed within 60 days of receipt of your completed test. A score of 70% or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the test. A contact hour is 60 minutes of instruction. Contact hour verification can be awarded only at the completion of a program.

Objectives

  1. Describe how discrimination impacts the lives of South African adolescents orphaned by AIDS.

  2. Identify ways in which faculty can assist college students following a disaster.

  3. Describe teaching strategies that can improve effectiveness of medication education.

doi: 10.3928/02793695-20111219-50

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