The Journal of Continuing Education in Nursing

Original Article 

Systematic Review of Continuing Education Interventions for Licensed Nurses Working in Psychiatry

Heather Hartley, MScN, RN; Jenna Donn Smith, BScN, RN; Amanda Vandyk, PhD, RN

Abstract

Continuing education is an important part of nursing practice. These interventions help maintain clinical competence and are mandated by regulatory bodies. Often, continuing education interventions are created ad hoc and implemented without testing or formal evaluation of learning outcomes. In the current health care context, where resources are limited, educators are pressed to do more with less. Having access to a repository of existing continuing education interventions will facilitate the use of evidence-informed learning strategies and save valuable time by reducing duplication of efforts. Therefore, this systematic review aimed to explore continuing education interventions for licensed nurses working in psychiatry. All standard systematic review procedures were followed, including double screening, data extraction, and quality appraisal. This article presents an inventory of existing interventions, including summaries, as well as the reported effectiveness of each for nursing outcomes. Generally, the continuing education interventions result in positive nurse-related outcomes, such as increased knowledge, confidence, and skills, or improved attitudes; however, more rigorous research is needed to advance science in this area. [J Contin Educ Nurs. 2019;50(5):233–240.]

Abstract

Continuing education is an important part of nursing practice. These interventions help maintain clinical competence and are mandated by regulatory bodies. Often, continuing education interventions are created ad hoc and implemented without testing or formal evaluation of learning outcomes. In the current health care context, where resources are limited, educators are pressed to do more with less. Having access to a repository of existing continuing education interventions will facilitate the use of evidence-informed learning strategies and save valuable time by reducing duplication of efforts. Therefore, this systematic review aimed to explore continuing education interventions for licensed nurses working in psychiatry. All standard systematic review procedures were followed, including double screening, data extraction, and quality appraisal. This article presents an inventory of existing interventions, including summaries, as well as the reported effectiveness of each for nursing outcomes. Generally, the continuing education interventions result in positive nurse-related outcomes, such as increased knowledge, confidence, and skills, or improved attitudes; however, more rigorous research is needed to advance science in this area. [J Contin Educ Nurs. 2019;50(5):233–240.]

Continuing education (CE) is necessary in self-regulated professions such as nursing (Griscti & Jacono, 2006). Professional and regulatory bodies mandate CE, which helps to ensure practice competence and lifelong learning (Canadian Nurses Association, 2018; College of Nurses of Ontario, 2002). The goals of CE are to improve quality of patient care by equipping nurses with up-to-date professional skills and to improve nurses' professional engagement (Engin & Cam, 2009; Gallagher, 2007; Lalonde et al., 2013). CE is shown to increase job satisfaction and staff retention (Kovner, Brewer, Wu, Cheng, & Suzuki, 2006; Levett-Jones, 2005); these learning opportunities should be readily available in all practice settings.

When patients require complex psychiatric care, they often work with specialized psychiatric services and nurses who possess advanced knowledge and skills. Increasingly, patients are accessing these services and yet administrators report a shortage of experienced nurses and challenges retaining existing staff (Adams, 2015; Bee et al., 2005; Thongpriwan et al., 2015; World Health Organization, 2007). Furthermore, nurses working in psychiatry report feeling overwhelmed by the complexity of patients in acute psychiatric settings and the ethical implications embedded in their care (Kontio et al., 2011; Lamont, Brunero, & Russell, 2010). This reality is echoed internationally, resulting in organizational strain and the erosion of the quality of care for patients with mental health needs (Chakraborty et al., 2006; Cleary & Walter, 2006).

Supporting nurses through CE is shown to improve professional competence, motivation to learn, and quality of patient care (Covell, 2009; Joyce & Cowman, 2007; Lahti, Kontio, & Välimäki, 2015; Nalle, Wyatt, & Myers, 2010; Patelarou, Vardavas, Ntzilepi, & Sourtzi, 2009). To increase the success of CE interventions, researchers suggest using evidence-informed strategies and tailoring initiatives to local needs (Robertson, Umble, & Cervero, 2003). Unfortunately, in the current health care context where resources are limited, several barriers exist for the implementation of rigorously developed and tested CE interventions (Shahhosseini & Hamzehgardeshi, 2014). Instead, it is commonplace for ad hoc quality improvement initiatives to unfold—that is, those developed simply by an individual and with limited evaluation or outcome measurement.

Scanning the online literature, we noted several published studies that describe the development and implementation of CE interventions for psychiatric nurses, including measures of effectiveness. Although it is pragmatic to make use of these existing interventions, the time needed to filter and search scientific literature to identify what is needed is often not feasible within the busy clinical environment. Through a systematic review, we aimed to inventory these existing CE interventions and report on the measures of effectiveness (outcomes and reported results) for each. The findings provide a comprehensive review of the available approaches to CE for nurses working in psychiatry and identify evidence-informed strategies that improve nurses' clinical competence.

The study aimed to explore CE interventions for licensed nurses working in psychiatry. The objectives were to inventory and describe CE interventions for licensed nurses working in psychiatry, and to summarize the outcomes associated with CE interventions for licensed nurses working in psychiatry.

Method

Design

This was a mixed-methods systematic review of studies on CE strategies for psychiatric nurses, modeled on the Joanna Briggs Institute (JBI) methodology (Godfrey & Harrison, 2010; JBI, 2014, 2016b). In collaboration with local stakeholders, we used the JBI methods to guide the development of the review protocol. The research team was from Canada and had expertise in psychiatric nursing, education, and review methodologies. Reporting of the review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009).

Eligibility Criteria

Eligibility criteria were established a priori using the Population, phenomenon of Interest, Context (PICo) tool. The population comprised licensed RNs and excluded nursing assistants, nurse practitioners, nursing students, and licensed nurses enrolled in a degree or diploma course. The phenomenon of interest was CE about the delivery of psychiatric patient care (any aspect). The context was inpatient adult psychiatry or mental health, and community/primary care and child/adolescent settings were excluded.

The study design included randomized controlled trials, controlled trials, observational studies (including cohort, case-control, cross-sectional, before-after, secondary data analysis, and case series studies) and qualitative studies, published in French or English.

Search

In collaboration with a library scientist, we developed a search strategy to capture pertinent literature. Using electronic databases (MEDLINE®, CINAHL®, PsycINFO®, EBSCO®, ProQuest®) the titles and abstracts of published articles were systematically searched using appropriate Medical Subject Headings (MeSH) (education, nursing, continuing; education, professional, retraining) and keywords (mental* or psychiat*, nurs*, and educat*) (Figure 1). The date range was 2008 to March 14, 2018, because this reflects the most current educational research (Table A; available in the online version of this article).

Search decision tree.

Figure 1.

Search decision tree.

MEDLINE® Search Strategy

Table A:

MEDLINE® Search Strategy

Study Selection

Three reviewers were responsible for study selection and used an online citation screening tool called Covidence® to manage this process. This software program allowed for complete screening of citations, it clearly displayed differences in reviewers' ratings, and it helped mitigate any issues pertaining to interrater reliability. Prior to initial screening of citations, duplicates were removed. The screening process then included four steps. First, two team members independently screened the titles of all retrieved citations to determine broad eligibility. Second, citations categorized as “included” or “unclear” by either reviewer were screened by abstract for relevance to the eligibility criteria. Third, both reviewers independently assessed the full texts of citations retained after abstract screening. The third reviewer helped reconcile conflicts that occurred during full-text screening. Finally, all involved reviewers participated in a team meeting to determine consensus on the included articles. Given the exploratory purpose of this review, all retrieved articles deemed relevant were included.

Data Extraction

We created a standardized data extraction form using Microsoft® Word. This form was pilot tested for interrater reliability using the first three included articles, and slight modifications were necessary to streamline the process and enhance accuracy. Using the finalized form, two reviewers independently extracted data from each included study. Data included general study information (authorship, publication date, country of study, purpose, study design, sample size, nursing population, psychiatric or mental health setting, guiding theoretical framework, data collection strategy), intervention characteristics (education modality, purpose and description, information on delivery, required resources), and reported findings (outcome measures, qualitative and/or quantitative findings pertinent to nurses). Next, the two reviewers compared their data extraction forms and when differences arose, studies were rereviewed and data were reextracted. Finally, we held a team meeting to discuss discrepancies with input from a third reviewer. Based on study objectives, extracted data were organized into summary tables to facilitate data synthesis.

Data Synthesis

We synthesized study information and CE intervention characteristics using original study data to develop descriptive statistics, including frequencies and percentages. Instruments used to evaluate nurse outcomes were heterogeneous and a meta-analysis of results was not possible. Instead, we reported the direction of statistically significant results for each intervention's outcomes and provided a summary table and narrative explanation. For qualitative findings, we created narrative summaries, highlighting the main findings. Finally, we created a table to inventory CE interventions designed to improve psychiatric patient care that measured outcomes in mixed health care professional samples.

Appraisal of Methodological Quality

Three reviewers participated in the appraisal of methodological quality to evaluate the included studies' potentials for bias using the JBI Critical Appraisal Tools available online (JBI, 2016a). The JBI Critical Appraisal Tools use focused questions to guide reviewers to identify the possibility of bias within a study's design, execution, and analysis. These tools are tailored to specific study designs and provide a final score from which researchers can assess methodological rigor. Prior to initiating the appraisals, the two reviewers responsible for independent appraisal met to clarify the interpretations of each question on the critical appraisal tools. For mixed-methods studies, we decided to appraise the qualitative and quantitative portions separately, which resulted in two scores, reflecting the methodological quality of each section. Given the exploratory purpose of this review, we opted not to exclude studies based on quality, but rather we summarized the appraisal results narratively to report on the state of science in this area (Table 1).

Critical Appraisal

Table 1:

Critical Appraisal

Results

After removing duplicates, we screened titles and abstracts of 3,310 citations for congruence with eligibility criteria. Three hundred ten potentially relevant citations (or those with insufficient information to determine eligibility) were retained. After full-text screening, we included 16 articles. Reasons for exclusion primarily included the following: unable to differentiate between nurse outcomes and other health care professionals included in the sample, wrong intervention (i.e., not about psychiatric patient care), and wrong setting (i.e., not inpatient mental health/psychiatric setting). We found 22 studies that were on topic, but which pooled data from nurses with data from other health care professionals (Table B; available in the online version of this article).

Studies Exploring Continuing Education (CE) in Psychiatry Including Nurses as Part of Their Sampled ParticipantsStudies Exploring Continuing Education (CE) in Psychiatry Including Nurses as Part of Their Sampled ParticipantsStudies Exploring Continuing Education (CE) in Psychiatry Including Nurses as Part of Their Sampled ParticipantsStudies Exploring Continuing Education (CE) in Psychiatry Including Nurses as Part of Their Sampled Participants

Table B:

Studies Exploring Continuing Education (CE) in Psychiatry Including Nurses as Part of Their Sampled Participants

Study Characteristics

The 16 studies were conducted in eight countries between the years 2008 and 2017: England (n = 3), Taiwan (n = 3), USA (n = 3), Finland (n = 2), Iran (n = 2), Australia (n = 1), Switzerland (n = 1), and Turkey (n = 1). Seven studies included a theoretical framework, although the specific theories used differed in all cases. Theoretical frameworks were used to inform intervention delivery or evaluation approach. Of the 16 studies, 14 were quantitative utilizing a combination of validated instruments and researcher-developed questionnaires to collect data. Sample sizes ranged from six to 178 participants. One study (n = 28 participants) was qualitative, with data collected through semistructured interviews, and one study was identified by the authors as mixed-methods (Table 2).

Characteristics of Included Studies

Table 2:

Characteristics of Included Studies

Interventions

The CE interventions covered nine topics relevant to psychiatric nursing care: recovery, substance use, motivational interviewing, medical care, managing difficult situations, critical thinking, case management, suicide, and mental health knowledge and attitudes. To deliver these interventions, three primary forms of education modalities were used: virtual learning, lectures, and small-group seminars. The amount of time required to complete the CE interventions ranged from 1 hour to 120 hours, divided over several months. The most common resources required included an instructor, meeting space, and a computer. Brief descriptions of the CE interventions are provided in Table C (available in the online version of this article).

Continuing Education (CE) Intervention CharacteristicsContinuing Education (CE) Intervention CharacteristicsContinuing Education (CE) Intervention CharacteristicsContinuing Education (CE) Intervention CharacteristicsContinuing Education (CE) Intervention Characteristics

Table C:

Continuing Education (CE) Intervention Characteristics

Outcomes

Twenty-five different instruments and four individual items were used to measure outcomes in the studies. Of these, 15 were researcher developed for the purpose of their study. Outcomes were heterogeneous, including measures of confidence, skill, knowledge, and attitudes. A change in knowledge about the topic covered by the CE intervention was most commonly assessed. The majority of results indicated a significant change in the expected direction (Table D; available in the online version of this article). For example, CE interventions aimed at enhancing nurses' knowledge reflected improvements in either knowledge in general or specific topics (e.g., seclusion) (Kontio et al., 2011). Other studies investigated additional outcomes; the CE intervention by Redhead, Bradshaw, Braynion, and Doyle (2011) resulted in a significant decrease of nurses depersonalizing patients, whereas Brunero and Lamont (2010) found significant increases in confidence and skills with statistically significant decreases in frustration levels following CE.

Reported Intervention Outcomes and ResultsReported Intervention Outcomes and ResultsReported Intervention Outcomes and ResultsReported Intervention Outcomes and Results

Table D:

Reported Intervention Outcomes and Results

Discussion

CE is a rewarding opportunity and a professional imperative for nursing specialties in many countries (Ross, Barr, & Stevens, 2013). CE is a process that allows for the acquisition of knowledge, skills, and professional growth. It improves nursing care of patients and their health outcomes (Garafalo, 2016; Rouleau et al., 2017). Although there is no professional consensus on the delivery of CE for nurses, these learning opportunities are a necessary part of ongoing professional competence and continuous learning. Positive effects, such as improved nurse retention, patient outcomes, and nurse resiliency, are associated with engagement in CE (Lim et al., 2016). Improving resiliency of nurses working in psychiatry is particularly important given the often morally and ethically challenging facets of their jobs (Kontio et al., 2011; Lamont et al., 2010).

The purpose of this mixed-methods systematic review was to inventory and summarize results of CE interventions for nurses working in psychiatric settings. Sixteen studies were included that focused on increasing knowledge, enhancing skills, or improving attitudes related to the delivery of psychiatric nursing care. Educational modalities and intervention length varied. Postintervention results revealed significant positive changes for most outcomes measured.

Heterogeneity of the Included Studies

Although most articles reported statistically significant results, it was not possible to pool results for meta-analysis because of the heterogeneity of the interventions and outcomes. Furthermore, the overall quality of the included studies was limited, and researchers are encouraged to use more robust study designs, recruit appropriate samples, and utilize psychometrically sound outcome measures to improve the state of the science in this area.

As identified in our eligibility criteria, we were interested in studies that included only licensed nurses practicing in psychiatric settings. This meant that we excluded studies in which the samples comprised multiple types of participants, such as nursing students, allied health personnel, or administrators, and we could not differentiate between participants' results. It is well documented that the learning needs of students or novice nurses differ from their intermediate or expert counterparts (Benner, 1984) and heterogeneous samples affect our ability to interpret results. We excluded 22 studies for this reason. For example, Tapola, Wahlström, and Lappalainen (2016) explored a CE intervention about self-injury, which had promising results. Unfortunately, the participants were pooled for data analysis and confounding effects were not accounted for. As such, the effectiveness of this intervention is unclear, limiting its transferability.

Clinical Applicability

A strength of the included studies was the addition of clinical applicability exercises and reflective activities embedded within the interventions. Brunero and Lamont (2010) and Hung, Tang, and Ko (2015) utilized scenario-based learning derived from actual clinical cases to encourage learners to analyze, synthesize, and design clinical care plans. Liu, Rong, and Liu (2014) and Hemingway, Trotter, Stephenson, and Holdich (2013) provided participants with cases from which they could explore management of different client scenarios. For the ePsychNurse. net e-Learning intervention, participants were asked to engage in reflective thinking, revisiting critical incidents from their practice and applying course learnings (Kontio et al., 2013; Lahti et al., 2015). Redhead et al. (2011) incorporated care plans and clinical observation into their educational strategy and evaluation. Although Hardy and Kingsworth (2015) described limited clinical applicability, nurse educators were required to provide education regarding relevant local mental health services that could be used by the learners in practice. Finally, the majority of interventions in this review incorporated reflection through the review of clinical cases. Reflection is an exercise shown to empower nurses, which has been linked to decreases in moral distress (College of Nurses of Ontario, 2015; Jackson, Firtko, & Edenborough, 2007; Wald, 2015).

E-Learning

Half of the included interventions utilized some form of e-learning. This approach to learning allows for prompt access to education despite geographical location or distance, using the Internet, e-mail, discussion boards, and videos (McKenzie & Murray, 2010). E-learning is also associated with reduced cost and is more time efficient than traditional learning methods (Rouleau et al., 2017).

E-learning methods are expanding and research in this area is evolving; however, its use is most prevalent in academic settings with nursing students (Rouleau et al., 2017). Yet, with staff shortages and limited resources, e-learning offers a viable approach to continuing education for licensed nurses as well (Dalhem & Saleh, 2014). To facilitate this, some professional associations have created e-learning networks. The Canadian Nurses Association, for example, launched a national online network called NurseONE that allows access to a variety of e-materials aimed to enhance professional competency and encourage up-to-date clinical practice (Canadian Nurses Association, 2012).

Although fiscally advantageous, researchers note that nurses report mixed views of e-learning compared with traditional in-person education modalities (Dalhem & Saleh, 2014). Also, evidence to support the effectiveness of this approach is limited (Sheen, Chang, Chen, Chao, & Tseng, 2008) and technical issues must be considered when implementing e-learning initiatives. Specifically, it is important that participants are adequately skilled and able to operate the technology required, and that real-time trouble-shooting is available for malfunctioning technology (Rouleau et al., 2017).

Limitations

Three limitations should be considered when using the results of this systematic review. First, as with all reviews, misinterpretation of the original research or data extraction errors are possible. To minimize this risk, two team members independently engaged in these activities, and discrepancies were discussed to reach consensus. Second, we were unable to include studies with mixed samples. Several of the CE interventions discussed in these studies were on topic, but their information is not included into this review. Given that we retrieved these studies with our search strategy, we thought it was useful to summarize their content and provide their citations in a supplemental file. Readers of this review are encouraged to refer to Table B when planning their education initiatives. Third, we were unable to pool results and comment on the overall effectiveness of CE for nurses working in psychiatric settings.

Conclusion

Engaging in CE is a requirement of professional nursing. These educational initiatives help to ensure continued relevant and competent nursing practice. Generally, the findings of this review suggest that CE interventions result in positive nurse-related outcomes, such as increased knowledge, confidence, and skills, or improved attitudes. However, more rigorous research and evaluation of CE interventions is needed. It appears as though CE interventions are created ad hoc when a clinical need is identified. This systematic review provides an inventory of existing interventions and information on their resource requirements and outcomes. To advance science in this area, it is important that sound, effective CE interventions are implemented and tested in various settings. We hope that nurse educators will use the information provided here in their planning efforts to choose evidence-informed strategies to ensure continued competence of their psychiatric nursing staff.

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  • Russell, R., Ojeda, M.M. & Ames, B. (2017). Increasing RN perceived competency with substance use disorder patients. The Journal of Continuing Education in Nursing, 48, 175–183. doi:10.3928/00220124-20170321-08 [CrossRef]
  • Shahhosseini, Z. & Hamzehgardeshi, Z. (2014). The facilitators and barriers to nurses' participation in continuing education programs: A mixed method explanatory sequential study. Global Journal of Health Science, 7(3). doi:10.5539/gjhs.v7n3p184 [CrossRef]
  • Sheen, S.H., Chang, W., Chen, H., Chao, H. & Tseng, C.P. (2008). E-learning education program for registered nurses. Journal of Nursing Research, 16, 195–201. doi:10.1097/01.JNR.0000387306.34741.70 [CrossRef]
  • Tapola, V., Wahlström, J. & Lappalainen, R. (2016). Effects of training on attitudes of psychiatric personnel towards patients who self-injure. Nursing Open, 3, 140–151. doi:10.1002/nop2.45 [CrossRef]
  • Thongpriwan, V., Leuck, S.E., Powell, R.L., Young, S., Schuler, S.G. & Hughes, R.G. (2015). Undergraduate nursing students' attitudes toward mental health nursing. Nurse Education Today, 35, 948–953. doi:10.1016/j.nedt.2015.03.011 [CrossRef]
  • Tsai, W., Lin, L., Chang, H., Yu, L. & Chou, M. (2011). The effects of the gatekeeper suicide-awareness program for nursing personnel. Perspectives in Psychiatric Care, 47, 117–125. doi:10.1111/j.1744-6163.2010.00278.x [CrossRef]
  • Wald, H.S. (2015). Professional identity (trans)formation in medical education. Academic Medicine, 90, 701–706. doi:10.1097/ACM.0000000000000731 [CrossRef]
  • World Health Organization. (2007). Atlas: Nurses in mental health. Geneva, Switzerland: Author. Retrieved from http://www.who.int/mental_health/evidence/atlas/atlas_nurses_2007/en/
  • Zuaboni, G., Hahn, S., Wolfensberger, P., Schwarze, T. & Richter, D. (2017). Impact of a mental health nursing training-programme on the perceived recovery-orientation of patients and nurses on acute psychiatric wards: Results of a pilot study. Issues in Mental Health Nursing, 38, 907–914. doi:10.1080/01612840.2017.1359350 [CrossRef]

Critical Appraisal

Joanna Briggs Institute (JBI) Critical Appraisal ToolStudy (Year)Total Score
Checklist for randomized controlled trialsRedhead (2011)8 of 13
Tsai (2011)9 of 13
Kontio (2013)9 of 13
Liu (2014)10 of 13
Checklist for quasi-experimental studiesArkan (2008)5 of 8a
Brunero (2010)6 of 7a,b
Hemingway (2013)5 of 8a
Aminoroaia (2014)5 of 8a
Hardy (2015)5 of 8a
Hung (2015)7 of 9
Repique (2016)5 of 8a
Attari (2017)5 of 8a
Ragaisis (2017)5 of 8a
Russell (2017)6 of 8a
Zuaboni (2017)c6 of 9
Checklist for qualitative researchLahti (2015)7 of 10

Characteristics of Included Studies

Study (Year)CountrySettingDesignSample (N)Guiding Theory
Arkan (2008)TurkeyHospitalPre–post52Not specified
Brunero (2010)AustraliaNot specifiedNonrandomized control trial23 (experimental), 23 (control)Action research methodology (Coghlan & Casey, 2001; Greenwood & Levin, 2005; Morton-Cooper, 2000)
Redhead (2011)EnglandHospitalRCT12 (experimental), 9 (control)University of Manchester Psychosocial Intervention (Everitt, 1999)
Tsai (2011)TaiwanHospitalRCT98 (experimental), 97 (control)Not specified
Hemingway (2013)EnglandNot specifiedPre–post9Not specified
Kontio (2013)FinlandHospitalRCT78 (experimental), 59 (control)Reflective learning (Lowe et al. 2007)
Aminoroaia (2014)IranHospitalPre–post63Not specified
Liu (2014)TaiwanHospitalRCT100 (experimental), 100 (control)Not specified
Hardy (2015)EnglandHospitalPre–post178 (module 1) 69 (module 2) 68 (module 3) 65 (module 4) 58 (module 5)Action learning (no reference)
Hung (2015)TaiwanHospitalNon-RCT + qualitative with interviews22 (experimental), 22 (control), 22a (qualitative study)McMaster University problem-based learning (Woods, 2000); adult learning theory (no reference)
Lahti (2015)FinlandHospitalDescriptive qualitative28Kirkpatrick's model (Kirkpatrick, 1996)
Repique (2016)United StatesHospitalPre–post + focus groups32 8 (focus group)Promoting Action on Research Implementation in Health Services Framework (Rycroft-Malone, 2004)
Attari (2017)IranHospitalPre–post + 3-month follow-up64Not specified
Ragaisis (2017)United StatesHospitalPre–post + 3-month follow-up8 (1 month post), 6 (3 months post)Not specified
Russell (2017)United StatesHospitalPre–post57Self-determination theory (Deci & Ryan, 2000)
Zuaboni (2017)SwitzerlandHospitalNon-RCT Pilot65b (experimental), 14b (control)Not specified

MEDLINE® Search Strategy

LineSearch
1(nurs* and ((mental adj1 health) or psychiat*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
2educat*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
31 and 2
4student*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
5education, nursing, continuing/ or education, professional, retraining/
61 and 5
73 or 6
87 not 4
9limit 8 to yr=”2008 -Current”

Studies Exploring Continuing Education (CE) in Psychiatry Including Nurses as Part of Their Sampled Participants

CitationContent of CE InterventionSample
Baker, J., Lovell, K., & Harris, N. (2008). The impact of a good practice manual on professional practice associated with psychotropic PRN in acute mental health wards: An exploratory study. International Journal of Nursing Studies,45(10), 1403–1410. doi:10.1016/j.ijnurstu.2008.01.004PRN medication administrationNurses Physicians
Treloar, A. J., & Lewis, A. J. (2008). Targeted Clinical Education for Staff Attitudes Towards Deliberate Self-Harm in Borderline Personality Disorder: Randomized Controlled Trial. Australian & New Zealand Journal of Psychiatry,42(11), 981–988. doi:10.1080/00048670802415392Borderline personality disorderNurses Allied health professionals Physicians
Treloar, A. J. (2009). Effectiveness of Education Programs in Changing Clinicians Attitudes Toward Treating Borderline Personality Disorder. Psychiatric Services,60(8). doi:10.1176/appi.ps.60.8.1128Borderline personality disorderNurses Allied health professionals Physicians
Endley, L., & Berry, K. (2011). Increasing awareness of expressed emotion in schizophrenia: An evaluation of a staff training session. Journal of Psychiatric and Mental Health Nursing,18(3), 277–280. doi:10.1111/j.1365-2850.2010.01683.xExpressed emotion in schizophreniaNurses Support staff
Rani, S., & Byrne, H. (2011). A multi-method evaluation of a training course on dual diagnosis. Journal of Psychiatric and Mental Health Nursing,19(6), 509–520. doi:10.1111/j.1365-2850.2011.01808.xDual diagnosisNurses Social workers Police Social welfare professionals
Robinson, T., Hills, D., & Kelly, B. (2011). The evaluation of an online orientation to rural mental health practice in Australia. Journal of Psychiatric and Mental Health Nursing,18(7), 629–636. doi:10.1111/j.1365-2850.2011.01712.xRural mental healthNurses Psychologists Social workers Occupational therapist Aboriginal mental health worker
Chambers, M., Gillard, S., Turner, K., & Borschmann, R. (2012). Evaluation of an educational practice development programme for staff working in mental health inpatient environments. Journal of Psychiatric and Mental Health Nursing,20(4), 362–373. doi:10.1111/j.1365-2850.2012.01964.xLived experience of patientsNurses Health care assistants Activity coordinators Occupational therapists Other
Edward, K., Hemmingway, S, & Stephenson, J. (2013). Oral health - a key assessment skill for mental health nurses: A pilot evaluation of an educational intervention. Mental Health Nursing, Dec 2012/Jan 2013, 12–16.Oral healthNurses Other
Goncalves, D. A., Fortes, S., Campos, M., Ballester, D., Portugal, F. B., Tófoli, L. F., . . . Bower, P. (2013). Evaluation of a mental health training intervention for multidisciplinary teams in primary care in Brazil: A pre- and posttest study. General Hospital Psychiatry,35(3), 304–308. doi:10.1016/j.genhosppsych.2013.01.003CommunicationNurses Physicians
Terry, J., & Cutter, J. (2013). Does Education Improve Mental Health Practitioners' Confidence in Meeting the Physical Health Needs of Mental Health Service Users? A Mixed Methods Pilot Study. Issues in Mental Health Nursing,34(4), 249–255. doi:10.3109/01612840.2012.740768Physical health needsNurses Health care support worker
Usher, K., Park, T., Trueman, S., Redman-Maclaren, M., Casella, E., & Woods, C. (2014). An Educational Program for Mental Health Nurses and Community Health Workers from Pacific Island Countries: Results from a Pilot Study. Issues in Mental Health Nursing,35(5), 337–343. doi:10.3109/01612840.2013.868963Mental health knowledge, skills, and attitudesNurses Community health workers
Castillo, E. G., Rosati, J., Williams, C., Pessin, N., & Lindy, D. C. (2015). Metabolic Syndrome Screening and Assertive Community Treatment. Journal of the American Psychiatric Nurses Association,21(4), 233–243. doi:10.1177/1078390315598607Metabolic syndromeNurses Psychiatrists Program coordinators Case managers
Mey, L. D., Çömlekçi, C., Reuver, F. D., Waard, I. V., Gool, R. V., Scheerman, J. F., & Meijel, B. V. (2015). Oral Hygiene in Patients With Severe Mental Illness: A Pilot Study on the Collaboration Between Oral Hygienists and Mental Health Nurses. Perspectives in Psychiatric Care,52(3), 194–200. doi:10.1111/ppc.12117Oral careNurses Students Social workers
Nicholas, A., Day, S., Pirkis, J., & Harvey, C. A. (2016). Mental health professional online development (MHPOD): Pilot testing of an online training package for Australian specialist mental health services. Focus on Health Professional Education: A Multi-Professional Journal,17(2), 4. doi:10.11157/fohpe.v17i2.134Knowledge, skills, and confidenceNurses Occupational therapists Psychiatrists Psychologists Social workers Other
Tapola, V., Wahlström, J., & Lappalainen, R. (2016). Effects of training on attitudes of psychiatric personnel towards patients who self-injure. Nursing Open,3(3), 140–151. doi:10.1002/nop2.45Self-harmNurses Clinical nurse specialists Physicians Psychologists
Bunyan, M., Crowley, J., Smedley, N., Mutti, M., Cashen, A., Thompson, T., & Foster, J. (2017). Feasibility of training nurses in motivational interviewing to improve patient experience in mental health inpatient rehabilitation: A pilot study. Journal of Psychiatric and Mental Health Nursing,24(4), 221–231. doi:10.1111/jpm.12382Motivational interviewingNurses Health care assistants Psychiatrists Clinical psychologists Occupational therapists Social workers Administrators
Ejaz, F. K., Rose, M., & Anetzberger, G. (2017). Development and implementation of online training modules on abuse, neglect, and exploitation. Journal of Elder Abuse & Neglect,29(2–3), 73–101. doi:10.1080/08946566.2017.1307153Abuse, neglect, and exploitationNurses Nurse practitioners Social workers Counselors
Fernando, A., Attoe, C., Jaye, P., Cross, S., Pathan, J., & Wessely, S. (2017). Improving Interprofessional Approaches to Physical and Psychiatric Comorbidities Through Simulation. Clinical Simulation in Nursing,13(4), 186–193. doi:10.1016/j.ecns.2016.12.004Interprofessional approaches to physical and psychiatric comorbiditiesNurses Physicians
Lavelle, M., Attoe, C., Tritschler, C., & Cross, S. (2017). Managing medical emergencies in mental health settings using an interprofessional in-situ simulation training programme: A mixed methods evaluation study. Nurse Education Today,59, 103–109. doi:10.1016/j.nedt.2017.09.009Medical emergenciesNurses Psychiatrists Health care assistants Activity coordinators
McEvedy, S., Maguire, T., Furness, T., & Mckenna, B. (2017). Sensory modulation and trauma-informed-care knowledge transfer and translation in mental health services in Victoria: Evaluation of a statewide train-the-trainer intervention. Nurse Education in Practice,25, 36–42. doi:10.1016/j.nepr.2017.04.012Sensory modulation/trauma- informed careNurses Allied health professionals Physicians
Meredith, P., Yeates, H., Greaves, A., Taylor, M., Slattery, M., Charters, M., & Hill, M. (2017). Preparing mental health professionals for new directions in mental health practice: Evaluating the sensory approaches e-learning training package. International Journal of Mental Health Nursing,27(1), 106–115. doi:10.1111/inm.12299Sensory modulationNurses Occupational therapists Social workers Psychologists Physicians Students Other
Yoshinaga, N., Nakamura, Y., Tanoue, H., Macliam, F., Aoishi, K., & Shiraishi, Y. (2017). Is modified brief assertiveness training for nurses effective? A single-group study with long-term follow-up. Journal of Nursing Management,26(1), 59–65. doi:10.1111/jonm.12521AssertivenessNurses Assistant nurses

Continuing Education (CE) Intervention Characteristics

Study (Year)ContentCE Modality and TimingDescription of CE
Arkan (2008)Medical care: Electroconvulsive therapy (ECT)Modality: Presentation, brainstorming, discussion, scenario study Timing: 1.4 hoursLecture and discussion about the effective mechanism of ECT, electrode placement, areas of use, complications, contraindications, seizure development, and nursing care before, during, and after ECT. After CE session, participants received an ECT information package. Resources: Instructor, meeting space, printed information package
Brunero (2010)Managing difficult situationsModality: e-learning modules and scenario-based learning Timing: 1 hourA three-part scenario after which the participants answered reflective- style questions. Upon completion of the CE intervention, the participants watched excerpts from the scenario that include reflection from patients, nurse experts, or academics. Resources: Computer with Internet
Redhead (2011)Mental health knowledge and attitudesModality: Small-group seminars (including clinical application and observation) Timing: 16 half-day sessions delivered over 8 monthsPsychosocial CE intervention training delivered by an instructor. Participants were asked to bring client care plans to stimulate group discussion and application of learning. Resources: Instructor, meeting space
Tsai (2011)SuicideModality: Lecture (large group) Timing: 1.5 hours (70 min. presentation and discussion of 20 min.)The Gatekeeper Suicide-Awareness Program focused on how to identify major depressive disorder, explored causes of depression and its relationship to suicide, high-risk groups, warning signs, and barriers to treatment and therapeutic engagement. Lecture-style presentation followed by group discussion. Resources: Instructor, meeting space
Hemingway (2013)Medical care: Diabetic careModality: Workshop Timing: 1 dayParticipants received a diabetes-focused clinical situation to research using a guided reading package. Following this, a DVD was played that included prompts, encouraging participants to identify symptoms, medications, and management options within the clinical scenarios Resources: DVD and DVD player, reading packages, meeting space
Kontio (2013)Managing difficult situations—seclusion and restraint useModality: e-learning, case studies Timing: 120 hours (over 3 months)The CE intervention used the ePsychNurse.net modules, which included reflective learning about seven topics. Each module entailed reading material, PowerPoint presentations, video lectures, discussion forums, and patient scenarios. Participants reflected on clinical incidents, and completed reflective assignments and self-awareness exercises. Resources: Instructors, ePsychNurse.Net access, computer with internet
Aminoroaia (2014)Mental health knowledge and attitudes (generally)Modality: Lecture (large group), large-group discussion and question and answer period, Small-group work Timing: 1-time session (timing not specified)A CE workshop comprising a lecture, question and answer period, and group work to cover four topics relevant to mental health/psychiatric care. Following the workshop, participants received a CD of educational material. Resources: Instructors, meeting space, educational material CD, computer
Liu (2014)Case managementModality: e-learning modules and case learnings Timing: 5 X 20 mins.Participants completed modules by attending virtual lectures and utilizing self-directed learning resources. Following each module, participants completed 10 self-assessment questions that required a passing grade. Participants were also able to reflect on a chosen case by watching videos of seasoned case managers sharing their experiences. Resources: Learning package, computer
Hardy (2015)Mental health knowledge and attitudesModality: e-learning modules, lecture (small group) Timing: 5 X 3 hours (lectures); e-learning timing not specifiedInstructors used curriculum guides to lead sessions, and offered participants manuals and resources to support their learning. BMJ Learning hosted the E-Learning modules and accessible online, covering topics such as alcohol and drug awareness, medications used in mental illness, the patient journey, care planning, and specific conditions. Lectures occurred on-site and the first session, covering basic mental health awareness, was mandatory (the other 9 sessions were optional). Resources: Meeting space, computer, learning package
Hung (2015)Critical thinking (regarding patient care)Modality: Problem-based learning seminar Timing: 5 X 6 hours (over 5 weeks)In tutor-facilitated sessions, participants received a clinical scenario. Based on the scenario they engaged in group discussions, identified learning issues, gathered health-related information, interpreted data, and explored relevant evidence. Participants synthesized their findings and proposed strategies through the development of care plans. Resources: Tutor, meeting space with white board, computer with internet, access to online journals
Lahti (2015)Managing difficult situationsModality: e-learning modules Timing: 120 hours (over 3–6 months)The CE intervention used the ePsychNurse.net modules, which included reflective learning about seven topics. Each module entailed reading material, PowerPoint® presentations, video lectures, discussion forums, and patient scenarios. Participants reflected on clinical incidents, and completed reflective assignments and self-awareness exercises. Resources: Tutors, ePsychNurse.net access, computer, meeting space, paid leave to engage in learning (40 hours)
Repique (2016)Recovery-oriented careModality: Online webinar Timing: 1 hourUsing a training program developed by Substance Abuse and Mental Health Services Administration focused on the application of mental health recovery principles in acute care settings, participants learned about patient engagement models, trauma systems theory, restraint reduction strategies, integration of peer-to-peer services in psychiatric treatment, and outcomes of randomized trials of consumer-managed alternative mental health treatment programs. Resources: Facilitator with expertise in recovery, meeting space,
Attari (2017)Medical care: Medication/ECTModality: Lecture, Q&A, group discussion Timing: 5 hoursA workshop on medication and medication administration, side effects, and electroconvulsive therapy. Educational material provided at the end of the workshop and participants received a CE credit. Resources: Instructor, meeting space, educational material
Ragaisis (2017)Motivational interviewingModality: Self-directed learning, experiential training Timing: 2 hoursHandouts disseminated to participants prior to the session with information on asking questions, delivering affirmations, using simple/complex reflections, and offering summary statements (based on Motivational interviewing assessment: Supervisory tools for enhancing proficiency [Martino et al., 2006]). Training session included brief overview of motivational interviewing, structured exercises on core skills (same topics as above handouts), and role-play between participants. Resources: Handouts, instructor, meeting space
Russell (2017)Substance useModality: Lecture Timing: 2 hours (offered multiple times)Instructor-led course focused on basic aspects of identifying, treating, and referring patients with behavioral and substance use disorders. Class designed based on a literature review and expert input. Five objectives: Discuss the categories of mental disorders and their impact on health care; Summarize current addiction theory, treatment, and recovery models; Examine the nurse's role in providing ethical, evidence-based care; Determine the resources available to patients and modes of referral; Explain how peer support and 12-step groups facilitate recovery. Resources: Instructor, meeting space
Zuaboni (2017)Recovery-oriented careModality: Lecture Timing: 5 X ½ dayTraining session 1: personal recovery and social inclusion based upon the REFOCUS training material (Bird, Leamy, Boutillier, Williams, & Slade, 2011) Training sessions 2 & 3: basics of Motivational Interviewing (Arkowitz, Westra, Miller, & Rollnick, 2008), development of therapeutic relationships, and coaching techniques (Grant, 2003) Training session 4: goal attainment strategies and goal attainment scaling (Hurn, Kneebone, & Cropley, 2006) Training session 5: implementation of the training contents into care process and documentation, as well as cooperation with other professional groups (Sauter, Abderhalden, Needham, & Wolf, 2011, pp. 347–396) Resources: Instructor, meeting space

Reported Intervention Outcomes and Results

Study (Year)Instrument (Reference)Validation ReportedOutcomes MeasuredResults
Arkan (2008)Observation form (researcher developed)YesNursing care throughout ECTMean ↑ p<0.05
Satisfaction form (researcher developed)NoPatients' level of satisfactionMean ↑ p<0.05
Survey (researcher developed)NoNurses' attitudes about ECTNot reported
Brunero (2010)Difficult Patient Stress Scale (Santammaria, 1996)YesLevel of frustrationDiff. btw grps. p=0.001 (lower in exp.)
Individual itemNoConfidenceDiff. btw grps. p=0.006 (higher in exp.)
Individual itemNoSkillDiff. btw grps. p=0.023 (higher in exp.)
Individual itemNoKnowledgeDiff. btw grps. p=0.003 (higher in exp.)
Redhead (2011)Knowledge Questionnaire (researcher developed)NoKnowledge↑ p<0.002
Attitude to PSI scale (Richards & Everitt, 1999)NoAttitudes↑ p<0.001
Maslach burnout inventory (Maslach et al., 1996)YesEmotional exhaustionDepersonalizationPersonal accomplishmentsns↓ p<0.018ns
Tsai (2011)Awareness of Suicide Warning Signs (researcher developed)YesKnowledge↑ p=0.000 (no Δ ctl. grp.)
Individual itemNoWillingness to refer for profession helpDiff. btw grps. p=0.03 (higher in exp.)
Hemmingway (2013)Knowledge Questions (researcher developed)NoKnowledge and understanding of diabetesMean ↑ (not tested)
Kontio (2013)Knowledge of Legislation (Immonen, 2005)YesKnowledge of coercion-related legislation↑ p=0.003 (no Δ ctl. grp.)
Physical Research Questionnaire/Knowledge Scale (Janelli et al., 1992)YesKnowledge about physical restraints↑ p=0.001 (exp.) ↑ p=0.001 (ctl.)
Seclusion Questionnaire/Knowledge Scale (Janelli et al. 1992/modified version 2007)YesKnowledge about seclusion↑ p=0.003 (no Δ exp. grp.)
Physical Restraint Questionnaire/Attitude Scale (Janelli et al., 1992)YesAttitudes towards physical restraintns
Seclusion Questionnaire/Attitude Scale (Janelli et al. 1992/modified version 2007)YesAttitudes towards seclusion↑ p=0.001 (no Δ exp. grp.)
Job Satisfaction Scale – Modified (modified Vartiainen 1986/based JDS, Hackman & Oldman 1974)YesJob satisfactionns
General Self-Efficacy Scale (Jerusalem & Schwarzer, 1992)YesPerceived self-efficacyns
Aminoroaia (2014)Knowledge Questionnaire (research developed)NoKnowledge of nursing care↑ p<0.001 (pre-post) ↑ p<0.001 (pre-3mos)
Attitude Questionnaire (researcher developed)NoAttitudes about nursing carens
Liu (2014)Knowledge Questionnaire (researcher developed)YesCase management knowledgeT1: higher in exp. (vs. ctl.) p<0.001 T2: higher in exp. (vs. ctl.) p<0.001
Hardy (2015)Questionnaire (researcher developed)NoKnowledge and attitudesMean ↑ p<0.05 (mod.1) Mean ↑ p<0.05 (mod. 2) Mean ↑ p<0.05 (mod. 3) Mean ↑ p<0.05 (mod. 4) Mean ↑ p<0.05 (mod. 5) Mean ↑ p<0.05 (all mod.)
Hung (2015)Critical Thinking Disposition Inventory (Yeh, 1998)YesCritical thinking overallSystematic analysisOpen-mindedCuriosityReflection↑ p=0.008 (no Δ ctl. grp.)↑ p=0.004 (no Δ ctl. grp.)ns↑ p=0.006 (no Δ ctl. grp.)ns
Qualitative findings

Diverse perspective thinking

Logical and systematic thinking needed to improve job performance

Effective practical application of clinical knowledge

Brainstorming learning strategy

Lahti (2015)Qualitative findings

The nursing managers reported that the nurses learned more about relevant legislation, ethical issues, and how to cope with aggressive patients

The nursing managers felt that after the course, the nurses were knowledgeable about alternative methods related to avoiding coercion

The nursing managers reported that the nurses' awareness of their own attitudes changed through self-reflection exercises

The nursing managers also described how the overall atmosphere and attitudes toward aggressive patients became more positive. They felt that the nurses' attitudes toward patient care and treating patients became more individualistic and collaborative

The nursing managers reported that the nurses cooperated more with distressed and disturbed patients; they added outdoor activities and involved patients more in decision-making. Nurses also tried to anticipate aggressive situations more.

Repique (2016)Recovery Knowledge Inventory (Bedregal, O'Connell, & Davidson, 2009)YesKnowledge, understanding and attitudes about: Roles and responsibilities in the recovery process Non-linearity of the recovery processRoles of self-definition and peers in recovery Expectations regarding recovery ns ns ns ns
Attari (2017)Knowledge Questionnaire (researcher developed)YesKnowledge about medical and non-medical interventions↑ p<0.001 (pre-post) ↑ p<0.001 (pre-3mos)
Attitude Questionnaire (researcher developed)YesAttitude about medical and non-medical interventionsns (pre-post) ns (pre-3mos)
Ragaisis (2017)Questionnaire (researcher developed)NoAgreement with using motivational interviewingPerceptions of using motivational interviewing between novice and seasoned nursesNo testing ns
Qualitative findings

Using motivational interviewing (MI) skills with other colleagues prompted greater thoughtfulness when responding in discussions

Nurses were able to elicit more detail using MI skills

MI skills gave the nurse a way to explore with patients' their perspectives

Through MI, respondents felt a sense of connection, of involvement, of advocacy, and being able to create a respectful and attentive space for patients

Russell (2017)Perceived competency questionnaire (researcher developed based on Lakeman (2010))YesFeel confident to care for them and believe recovery is possible Make the approach with a positive, nonjudgmental attitude Know what questions to ask if I suspect drug or alcohol use Refer them to resources in the community and motivate them to seek help↑ p<0.001 ↑ p<0001 ↑ p<0.001 ↑ p<0.001
Zuaboni (2017)Recovery Self-Assessment scale – D (Zuaboni et al., 2015; O'Connell, Tondora, Corrg, Evans, & Davidson, 2005)YesPerceptions of the degree to which mental health services implement recovery-oriented practicesns (total score and all subscales – pre/post and exp./ctl.)
Authors

Ms. Hartley is Registered Nurse and Professional Practice Specialist, Ms. Smith is Registered Nurse, and Dr. Vandyk is Assistant Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Benjamin Hartung, School of Nursing, University of Ottawa; Dania Versailles, Hôpital Monfort; and Emily Marcogliese, School of Nursing, University of Ottawa, Ontario, Canada.

Address correspondence to Heather Hartley, MScN, RN, Registered Nurse, Professional Practice Specialist, Quinte Health Care: Belleville General Hospital, W-378, 265 Dundas St. E., Belleville, ON, Canada K8N 5A9; e-mail: hhart029@uottawa.ca.

Received: June 20, 2018
Accepted: November 27, 2018

10.3928/00220124-20190416-10

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