The significance of the clinical component of nursing education has long been recognized (Dachelet et al, 1981; Brockhaus, Woods, & Brockhaus, 1981). The time students spend in a clinical setting is limited and learning opportunities may occur unexpectedly. Therefore, it is imperative that variables which have an impact on learning experiences be given careful consideration. To enhance the clinical experience, teachers must be able to identify and deal with those factors which most influence learning. One of these factors is the level of the student's anxiety. Anxiety is often precipitated by a strange environment and by students' perceptions that they do not have enough information about their patients' conditions to provide optimum nursing care.
It is very important for the student to read the client's chart in the medical-surgical setting in order to provide safe physical care. It is also important for the nursing student to have access to chart information when planning nursing care for an extended period, for the psychiatric client. However, it is not essential that the chart be read prior to the initial verbal interaction with an individual in the psychiatric setting. Students have a great deal to learn, but they already possess beginning skills in relating to clients. Reading the chart may provide important information, but it may also cause the student to formulate preconceived ideas about the client. The desire for chart information may be more indicative of anxiety than of the desire for information that will be needed in the first interaction with the client. This article addresses the effect of reading, or not reading, the client's chart on nursing students' anxiety levels prior to the first interaction with clients in the psychiatric setting.
Review of the Literature
As nurse educators attempt to prepare nursing students for the clinical practicum, the students' emotional responses to the clinical experience must be assessed. Joachim and Thorne (1980) reported that nursing students in a baccalaureate program regarded the clinical experience as the most anxiety-producing component of their nursing program. In discussing the need to adequately prepare students for the clinical experience it has been noted (Blau, 1983; Lewis, Gadd & O'Connor, 1987) that new clinical rotations cause anxiety in students. Some anxiety helps the person to act efficiently and quickly and is thought to be beneficial. However, when the intensity of the anxiety is too high, perceptions are narrowed, the individual is immobilized, and learning is impeded (Blainey, 1980; Joachim, 1981; Knowles, 1981). Thus, before teaching can be carried out, the students' emotions have to be considered (Blau, 1980) and an essential part of clinical instruction is helping students control anxiety that may interfere with learning (Lewis et al., 1987).
Williams (1970) found that the beginning of a clinical experience was more anxiety producing than the latter part of the experience, and suggested that anxiety be assessed and dealt with during orientation, as well as throughout the practicum. Lewis, et al. (1987) conducted a study to "evaluate the relationship between the interval from orientation to the first patient care day in medical/surgical nursing and the students' stated anxiety and their ability to recall orientation information" (p. 96). They found that students who had to wait 6 days before applying the orientation information to the clinical setting had greater anxiety than those who did patient care the day after the orientation.
The clinical experience in a psychiatric setting seems to be one of the most anxiety-provoking of all the clinical experiences. Schoffstall (1981) observed that "stereotypes associated with mental patients and psychiatric hospitals can have a powerful impact on the student nurse who is about to begin an affiliation in psychiatric-mental health nursing"(p. 11). Marley (1980) noted that "nursing students enrolled in a baccalaureate nursing program approach their psychiatric clinical rotation with feelings that range from anticipation to high level anxiety" (p. 16). Another author (Blau, 1983) wrote that the psychiatric practicum is a sensitive area for students who feel hostile and fearful about the experience.
Stacklum (1981) noted that psychiatric nursing students had difficulty in decision making and demonstrated avoidance behaviors. She concluded that these responses are due to anxiety. Burgess (1981) noted that the students' desire to know many details about clients prior to talking with them may be due to anxiety and that knowledge of historical data may reduce the students' anxious behavior.
Although methods to assist students in dealing with anxiety in the psychiatric setting have been reported in the literature (Marley, 1980; Schoffstall, 1981; Stacklum, 1981) no studies have been found which sought to identify whether reading clients' charts before initiating interaction with them will influence the degree of anxiety experienced by beginning psychiatric nursing students. Burgess (1981) observed that there is controversy about the necessity of having background information about the patient before the first interview. A paucity of information exists in this area, and nurse educators have not reached agreement on the advisability of providing nursing students with information about the psychiatric clients before their first interactions with these clients. Because of this, the study was designed to determine the effect of reading clients' charts on the anxiety level of nursing students in the psychiatric setting on the first day of their clinical experience.
Spielberger's (1966) State-Trait theory of anxiety was used as the framework for this study. State anxiety is defined as a current feeling of emotional and physical uneasiness. State anxiety is a transitory condition which varies in intensity and fluctuates over time in reaction to stressful circumstances. Trait anxiety refers to an individual's anxiety proneness. It is viewed as a relatively stable personality trait.
Spielberger (1972) suggested that the terms stress, threat, and anxiety are often used interchangeably. However, in his theory, he uses the term stress to refer to the objective stimuli. These stimuli may include variations in environmental conditions or circumstances that occur naturally or that are introduced by the researcher. Whether a situation is perceived as threatening depends upon an individual's subjective appraisal of the situation.
Non-stressful situations may be appraised as threatening by some individuals. This perception is determined partly by personality disposition and by past experiences with similar situations. If the situation is perceived as threatening, there will be an elevation in state anxiety. State anxiety should be low in circumstances where an existing danger is not perceived as threatening. Persons who have high trait anxiety tend to perceive a larger number of situations as dangerous or threatening and respond to threatening situations with state anxiety elevations of greater intensity than persons who are low in trait anxiety.
An objective, stressful stimulus for subjects in this study was the first interaction with psychiatric clients. It was proposed that being asked to refrain from reading clients' charts would be a potential stressor for nursing students.
Taking pre-treatment anxiety levels into consideration, anxiety levels prior to interactions with psychiatric clients are lower among students who have been asked to read their clients' charts, than among students who have been asked not to read the clients' charts.
Design and Methods
A true experimental design was utilized in this study. An experimental and a control group were formed through random assignment of subjects to groups. Data were collected in field settings. Two psychiatric clinical facilities were used. One of the settings was a non-profit, governmental hospital and the other was a private psychiatric facility.
The target population for this study was undergraduate nursing students in their first clinical experience with psychiatric clients. The accessible population was composed of junior nursing students in one school of nursing in the southwestern United States. These students were beginning their first experience in psychiatric nursing. Clients selected for student assignments on the first day of the psychiatric experience had varying diagnoses. However, all clients had to be able to verbally communicate and not be acutely disturbed. A total of 119 nursing students volunteered to participate in the study during the three semesters in which data were collected.
STATE ANXIETY MEAN SCORES OF READERS AND NON-READERS AT THREE TESTING PERIODS
At the beginning of the psychiatric clinical experience during each of the three semesters of data collection, students were informed about the study, and volunteers were sought. This took place at the beginning of the first day of psychiatric clinical experience while students were gathered together in a conference room for orientation to their respective agencies.
Each student was asked to choose an envelope from a box on a table. Half of the envelopes were marked Group 1 and half were marked Group 2. Each envelope contained four questionnaires. Those students who did not wish to participate in the study were told to return their blank questionnaires in the envelope at the end of the day. Students were instructed not to put their names or any identifying information on the questionnaires in order to protect their anonymity.
Instructions were then given to take out questionnaire #1 (State Anxiety) and questionnaire #2 (Trait Anxiety). Students were asked to complete the two questionnaires, in order, after the instructors left the room. Students were then given an orientation to their respective agencies. These presentations lasted approximately 1 hour.
Students were then given their individual clinical assignments, which included the psychiatric unit to which they were assigned and the patients they would be caring for during the day. Students in Group 1 (readers) were asked to spend some time reading the charts of their clients before interactions with these clients. Students in Group 2 (nonreaders) were asked not to read the charts of their clients prior to interactions. Following these instructions, students were asked to complete questionnaire #3 (State Anxiety) while the instructors again left the room. Students then went to the various psychiatric units for the next several hours.
At the end of the day when all students were again gathered together in their post-clinical conferences, questionnaire #4 (State Anxiety) was completed. Students were then asked to place their envelopes containing the four questionnaires in a box on a table in the conference room. All students completed the questionnaires. However, one student did not correctly follow the instructions for completing the questionnaires. Therefore, data were analyzed on returns from 118 subjects.
TRAIT AND STATE ANXIETY SCORES OF READERS AND NON-READERS
The tool used to collect data was the State-Trait Anxiety Inventory (STAI) developed by Spielberger, Gorsuch and Lushene (1970). STAI Form X was used in this study. Form Y (Spielberger, Gorsuch, Lushene, Vagg & Jacobs, 1983) is commonly used today because of its ability to more clearly distinguish anxiety and depression. However, "for most clinical and research applications, the two forms may be considered essentially equivalent for the assessment of anxiety" (Spielberger et al., 1983, p. 10). The STAI consists of two 20-item, self-report scales for measuring state and trait anxiety. Subjects rate themselves on a four-point scale which indicates the intensity of their anxiety. Possible scores vary from a minimum of 20 (low anxiety) to a maximum of 80 (high anxiety).
Normative data are available from large samples of college students, high school students, psychiatric patients, general medical-surgical patients, and prisoners. Testretest correlations for the trait scale range from .73 to .86, while those for the state scale range from .16 to .54. Due to the transitory nature of state anxiety, these low correlations were expected. Therefore, internal consistency reliability is a more accurate determination of reliability for this part of the tool. Alpha coefficients range from .83 to .92 for the state scale. Alpha coefficients for the trait scale range from .86 to .92.
Of the 118 subjects in the study, 58 (49% ) were assigned to the chart reading group and 60 (51%) were assigned to the non-reading group. Data displayed in Table 1 and the Figure show mean scores of subjects during the three testing periods. One measure of trait anxiety and three measures of state anxiety were obtained.
The hypothesis was used to determine if state anxiety levels would be similar between the two groups after students were told that they were in the reader or nonreader groups. Using trait anxiety scores and the first state anxiety scores as covariates, no significant difference in state anxiety was found between the two groups (F= 0.80; df = 2; ? = .37) (see Table 2). Additionally, students' levels of state anxiety at the end of the first day of clinical experience were measured. Using trait anxiety scores and the first state anxiety scores as covariates, the final measure of state anxiety showed no significant difference between students who had read charts and those who had not read charts (F = 0.05; df = 2; p = .83).
Further analysis of the data from this sample show two findings of particular interest to the investigators. First, examination of the data indicate that trait anxiety is the best predictor of state anxiety. Second, this predominantly female sample reported mean state anxiety scores similar to the normative sample tested by Spielberger. Total mean state scores before the clinical orientation were only slightly lower (40.19) for the present sample than Spielberger's normative sample (43.69) who were measured following an "exam" period. At the end of the first clinical day, the students' total mean state scores (33.34) were somewhat similar to the norm group's "relaxed" state (29.60).
It is significant that the state anxiety scores for both groups were similar on the second testing. Although the reader group decreased slightly and the non-reader group increased slightly, the scores were very similar. This suggests that for most of the students, reading or not reading the clients' records did not appreciably affect anxiety levels. Also, it is important to note that students' anxiety levels at the end of their first day of clinical experience were only slightly elevated above that of a relaxed state.
ANALYSIS OF COVARIANCE OF STATE ANXIETY FOLLOWING ASSIGNMENT TO READ OR NOT READ CLIENTS' CHARTS
Implicit in the literature is the need to facilitate student learning. As curriculums are increasingly filled with a variety of "needed" experiences, time allocated to traditional specialty areas has decreased. Further, clinical facilities are in short supply. It is important to take full advantage of every client contact for a full range of experiences.
Based on the anxiety theory utilized as the basis for this study, it may be concluded that the objective stimulus of reading/not reading client records, coupled with the first interaction with psychiatric clients, does not appreciably influence state anxiety responses. If mild to moderate anxiety enhances learning, it can be speculated that this sample of students may perform as well in this experience as in other clinical rotations.
The mild/moderate levels of student anxiety might have been due to the quality of the general orientation given to students. All three instructors with students in the clinical areas had significant clinical teaching experience ranging from 8 to 12 years in undergraduate psychiatric nursing education. On the other hand, the sophistication levels of todays students might have influenced them to report socially desirable answers to the instrument rather than their true anxiety levels. Because of multiple administrations of the same test to the subjects, the external validity of the study is decreased. The results could not be generalized to other groups who were not also exposed to the reactive effects of testing.
Although further investigation of the influence of chart reading on the anxiety levels of students might be undertaken through the use of more objective means of measuring anxiety, it may be more useful to investigate other sources of anxiety in students beginning a psychiatric nursing experience. Unless further research reveals different findings than those of this study, instructors can be flexible in their decision to allow students to read or not read clients' charts prior to the first interactions with psychiatric clients. Nurse educators may wish to allow the student to make his or her own decision about reading or not reading the clients chart on the first day of the psychiatric experience, after being told the advantages and disadvantages of such a decision.
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TRAIT AND STATE ANXIETY SCORES OF READERS AND NON-READERS
ANALYSIS OF COVARIANCE OF STATE ANXIETY FOLLOWING ASSIGNMENT TO READ OR NOT READ CLIENTS' CHARTS