Researching Rural Generalist Nurses - Essay Example

Critique of Article Researching Rural Generalist Nurses Part A Information about rural generalist nurses, whether service-specific or broad-based (i.e., issues of training or communication) is relevant to the nursing community worldwide. Rural nurses can be found in every populated continent: Africa (Mathole 385-393), Asia (Yamashita 156-165), Australia (Pinikahana 120-125; Lauder et al., 337-344, 2001), Europe (Richards 2-7), North America (Bushy and Leipart 387), and South America (Beckmann 238-241). Therefore, what is important to the rural nursing community is, by design, important to untold millions of men, women, and children across the globe. In Australia, rural nurses represent an impressive percentage of the nursing community. According to the Association for Australian Rural Nurses, Inc. (Mission and Objectives), there are 90,000 Australian rural nurses. Drury (Online) commented that nurses in rural and remote areas of Western Australia are often sole practitioners, and that community mental health nurses were often sole care providers, responsible for coordinating all aspects of the clients’ care. Therefore, research relating to these 90,000-strong women and men is important to nursing and clinical practice. Topical research, such as treating patients with mental health problems, an area that challenges not just generalist nurses but also well-schooled mental health professionals, is certainly welcomed. The interest is not just theoretical, it is financial, too. The Australian Medical Association’s Submission to the Senate Select Committee on Mental Health (April 2005) noted that between 2000-2001, four mental health-related concerns (Mental Disorders, Nervous System Disorders, Alzheimers/Dementias, Other Nervous System) were responsible for over 25% of the health spending in Australia. The raw figure for spending is in the untold millions. Thus, the provision of timely, appropriate, mental health care is not just an ethical or social imperative, it is a financial one, too, and information pertaining to such care is valuable. Clark et al.’s (205-213) article, “Rural generalist nurses’ perceptions of the effectiveness of their therapeutic interventions for patients with mental illness,” according to the title, states it will discuss the nurses and “perceptions of the effectiveness of their therapeutic interventions for patients with mental illness” (205), certainly an important topic. This content description is echoed in the last paragraph of the Introduction, also. However, after reading one or two pages of the article or reviewing the survey instrument, it is evident that no questions asked pertained to therapeutic interventions. The survey questions dealt primarily with feelings and opinions about working with the mentally ill, but not how or what they did when they dealt with these patients. At no point in the article did the authors discuss “therapeutic interventions” per se, what therapies the nurses used to help the mentally ill. Nor did the survey address the nurses’ perceived effectiveness of specific therapies. The Objective, the first line of the paper, is the first hint that the paper will not discuss what the title presents when it reads, “To explore generalist nurses’ perceptions of their efficacy in caring for mentally ill clients in rural and remote settings…”As the title is the initial focus for most readers, a misleading title defrauds the reader base, and continuing the fraudulence to the end of the Introduction is unacceptable. The methodological approach, a mailed questionnaire, however, is sound. Given the distances the nurses cover and the remote locations covered (Roma and Charleville HSDs), in-person interviews would be difficult. Mailed questionnaires to collect information from rural respondents have been used in similar studies, specifically Stewart et al. (122-145) in their study of registered nurses in rural and remote Canada; Richards et al. (2-7) in their study of attitudes of doctors and nurses toward eHealth in rural United Kingdom; and Chang et al. (542-551) in their effort to understand continuing education needs in order to develop rural and remote nurses’ mental health knowledge and skills. Clark et al.’s (205-213) use of a Likert scale for responses to the survey questions is standard, notwithstanding its use by the authors of the questionnaires upon which Clark’s survey was grounded. Likert scales are generally easy for respondents to complete, but they engender interpersonal differences in response interpretation, i.e. how is “strongly disagree” interpreted from one person to the next? Given that Clark et al.’s respondents completed the questionnaire at their chosen site and the authors did not state if they sent a cover letter with the survey indicating a phone number for respondents to call if they had questions about survey completion, this interpersonal variability could significantly confound the response data. Part B Clark et al.’s (205-213) topic, rural generalist nurses provision of mental health services, is well worth researching. However, it is important to assess the components of the authors’ research methodology to help ascertain the paper’s contribution to the rural nursing field. Problem Definition The Abstract, where one looks to understand the problem the authors are researching, should be a high-level summary of the findings of the paper. In the Abstract to Clark et al.’s paper, the authors state, “Rural nurses do not feel competent, nor adequately supported, to deal with patients with mental health problems.” Perhaps this statement might have been more accurate had it read, “70% of rural nurses who responded…” or “A majority of rural nurses…” From reviewing the survey data in Tables 3, 4, and 5, it is clear some nurses do feel competent and adequately supported in providing mental health services, as otherwise the answers to all the positively-phrased questions would be zero. While some rural nurses do not feel competent, stating, “Rural nurses do not feel competent…” without modification lets the reader believe that any and all rural nurses do not feel competent. This is certainly not the case, and problem definition (and outcome) is misrepresented. As previously noted, Clark et al.’s (205-213) Introduction, where the reader expects to find problem definition, includes a sentence at the end misleading readers of the content of the article, “This paper examines rural generalist nurses’ perceptions of the effectiveness of their therapeutic interventions for patients with mental illness, and the nurses educational needs” (205). As discussed in Part A, this is not the subject of the article and does not address the actual problem to be discussed. However, the key words (mental illness, professional development, role competency, role support, therapeutic commitment) do reflect the content of the article and facilitate problem definition. Unfortunately, key words such as “nurse,” “rural,” or “education,” - the stated areas of interest or the study – were not included. Though the authors devoted several paragraphs to the concepts of role support, role competency, and therapeutic commitment as integral dimensions to study, they failed to make the connection between a nurse’s feelings (response) along these dimensions, and the actual impact this has on her/his service. Persons across all fields often feel unprepared or ill equipped to do their job, but if they continue to perform well the feeling could be simple insecurity and not disabling anxiety. More succinctly, do scores on these dimensions have anything to do with patient care – certainly feelings are important but patient care is paramount. Literature Review Of note in Clark et al.’s literature review is the singular absence of Lauder et al.’s (221-231, 2000) “The development and testing of the Mental Health Problems Perception Questionnaire” (heretofore referred to as the MHPPQ). Given Clark et al.’s usage of the MHPPQ, minimally modified, it is not unreasonable to expect that they would include sufficient source documentation on the MHPPQ so interested readers can review the original MHPPQ, understand the rationale for its development, and learn more about its reliability and validity testing. This information is succinctly presented in Lauder et al.’s (221-231, 2000) article, which also includes a copy of the original MHPPQ. However, Clark et al. (205-213) chose not to provide readers with this information, significantly hindering readers’ capacity to thoroughly understand the survey instrument at hand. With the exception of works from William Lauder, PhD., the researcher in Great Britain whose questionnaire they modified, the authors included no works from international authors. As noted at the outset of this paper, issues of rural nursing span the globe. Canadian authors are prolific in studying and publishing on this topic, notably Stewart et al.’s, “A profile of registered nurses in rural and remote Canada” (122-145) and Letvak’s United States study, “The importance of social support for rural mental health” (249-261) which specifically discusses the strategies to assist rural nurses (249). Clearly, the international community is also struggling with issues pertaining to rural health nursing and researchers focusing on rural health nurses in Australia can also learn from international counterparts. Furthermore, the literature review could have been stronger with more timely references. The article indicates it was accepted in March 2005 yet it includes no references past 2002, and one-third (6/18) are from before the year 2000. Relevant research was conducted during this time; Pinikahana et al. (120-125) published a highly relevant paper, “Stress, burnout and job satisfaction in rural psychiatric nurses: A Victoria study” in 2004. The international community was publishing, too, including Richards et al.’s study (2-7) published in early 2005 on eHealth for nurses and doctors working in geographically isolated areas of the United Kingdom. Ongoing research was also underway by the Association for Australian Rural Nurses, Inc. (Missions and Objectives). Unfortunately, Clark et al.’s literature review does not do justice to the research done at home and abroad in their chosen field. Research Design Research design, as summarized by Kane and O’Reilly-De Brun, is the “combination of the outline, sources of information, and research techniques necessary to develop the paper.”(57-60). With Clark at al’s (205-213) article, the authors’ research technique, modifying the MHPPQ and sending it to rural generalist nurses, was theoretically sound but imperfect in execution. The authors state they modified the MHPPQ by removing 3 statements and adding 11 (206). However, they failed to note one very important modification they made. Lauder et al. (221-231, 2000) in their original publication describing the development and testing of the MHPPQ, referred to the nurses’ patients as patients with “mental health problems.” Clark et al. (205-213) however, changed the verbiage and when they asked the nurses about working with patients they asked about patients with “mental illness”. The distinction between mental health/mental illness is not simply semantics. “Mental illness,” to many, conjures the image of someone needing ongoing medical treatment from a psychiatrist, perhaps hospitalization, or simply that the patient is just “crazy.” “Mental health problems” is a more benign phrase, and could easily refer to a patient needing reassurance for intermittent generalized anxiety but not needing complicated treatment protocols as do the “mentally ill.” (Mental Illness) When the nurses responded to the survey, did the authors have any way of knowing if the nurses were responding considering only patients with organic, medical-model mental health problems (mental illness) or did the nurses consider any patient they visited who had “mental health problems” as an appropriate candidate for response? In the absence of knowing this answer, the validity of the survey results is strongly in question. Another design issue pertained to the fact that two answers along the Likert scale included the word “quite.” “Quite” to most Australians means “not as much.” Westerners, particularly Americans, define “quite” as “to the greatest extent, completely.” (“Quite”) Thus a Likert scale with “Quite Strongly Disagree” as a lesser choice to “Strongly Disagree” would perplex Westerners but would be logical to Australians. Clarification on this matter was secured from Dr. Lauder (eMail, 9 January 2006) the author of the study upon which Clark et al. (205-213) based their survey. Dr. Lauder stated that there was a cultural difference between the American and British definitions, but that the British used “quite” as a qualification, less emphatic. Though logical to Australians, it would have made the survey more culturally sensitive to use words that had common definitions in case respondents were from foreign countries where certain words were used differently. Sampling Clark et al. (205-213) used a standard, non-probability sample, a “purposeful” sample that gets “‘information rich’ material from special groups” (Kane & O’Reilly-De Brun 100). As the authors only wanted information on rural generalist nurses, there was no attempt to have a random sample of regional nurses in Roma and Charleville HSDs. The authors’ response rate of 47% (N=163) is not uncommon in mail-in surveys and the “N” would probably be considered by many as appropriate for analysis. The authors noted that the attitudes of respondents might be different from non-respondents, so the response pool may not provide an accurate reflection of the rural generalist nursing community under survey. However the authors did not note that the attitudes of nurses in the Roma and Charleville HSDs, the only Districts surveyed, might not be representative of nurses across Australia, also known as a concern of generalisability. Sweeping generalisations such as “Rural nurses do not feel competent…” might not reflect the feelings of rural nurses elsewhere, both in Australia and internationally. Data Collection Strategies In the Results section of the article, the authors note, “Because respondents in this study were able to select multiple categories, in order to reflect their entire history of education and training, data analysis could not be conducted to examine the effect of education and training on levels of therapeutic commitment, role competency, and role support.” To the informed reader, this represents a serious fault in survey design and data collection. The Objective of the article states, “…and their educational needs in the area of mental health care” yet the authors designed a study whereby they were unable to examine education or training and its impact on how the nurses responded. One wonders why the authors did not modify the data collection instructions to state, in the section where multiple answers were provided, “Please select only one category. Please choose the category that best fits your education (training) at this time.” Providing such instruction would, perhaps, have yielded the data necessary to provide more validity to the conclusions of the study. Data Analysis Strategies The authors consistently made reference to statistical measures such as ANOVA, Tukey post-hoc test, “t” scores, and assorted other concepts (“F” “P”) in the data analysis paragraphs. However, they provided little interpretation or analysis regarding the meaning of these values as related to the study question. While some testing may have shown no statistical significance, it would have strengthened the paper to analyze the meaning of the lack of significance, as well as discussing statistical significance. Mention of the significance of scores for role support, role competency, and therapeutic commitment vis a vis patient care, which was absent in Problem Definition, was absent in Data Analysis also. The authors did analyse data, but not to a level that rendered the data meaningful - for example, it is helpful to know that 62% of the nurses felt their knowledge was inadequate, but the authors needed to take the next step – noting if there a relationship of high/low scores to nurse tenure, patient satisfaction, medication errors and related issues. In addition, data analysis of demographic data was inconsistent. The authors discussed some demographic data, i.e., nursing qualifications or clinical experience. But other important data went unnoticed. That more than 65% of respondents had worked as a nurse in a rural setting for more than 5 years, with 42% working more than 10 years, is significant but was not discussed (207). Nurses with more than 10 years in the field probably completed their training more than a decade ago, and might feel less well equipped to work with those with mental illness as a function of time out of university. It would be valuable to assess if new graduates are getting different, more in-depth education and feel better equipped, as a function of more recent coursework. In addition, most new graduates used computers in university. Information technology is being implemented to support rural health care practitioners (Richards 2-7, Chang 542-551) but some long-term field workers may not have access, yet, to these technologies or have the proficiencies of their younger contemporaries. Further, the authors discuss how factors such as frequency of contact with the mentally ill and experience with a friend/family with mental illness impacted nurses’ self-perception. But neither of these two parameters was shown as a question on any part of the questionnaire as published. If these two parameters were not shown, were there other ones that were not? Findings, Conclusions, Recommendations The authors reiterate the nurses’ concerns with role support, role competency, and therapeutic commitment, but they make virtually no substantive recommendations about how to remedy the situation. They reiterate a scenario of “doom and gloom” with vast numbers of nurses feeling unprepared to do their job, but they do not make suggestions such as continuing education programs, technology-based training or field trainings to ameliorate the situation In addition, they comment that their results “argue that the current three-year courses do not allow sufficient time for the development of general knowledge…” In reality, their results make no such argument. The results simply indicate that the respondents did not feel comfortable treating the mentally ill, but the survey results do not address whether the current three-year programme is satisfactory or not. It was previously noted in this paper that the title of the article did not reflect its content. A similar misrepresentation concludes the article. The last three lines of the Conclusion state that, “…barriers exist that reduce the capacity of nurses in these HSDs to provide effective health care to people with mental illness” (212). However the provision of health care was not what the article discussed – it discussed the provision of mental health services; such an error weakens the validity of the article. Interestingly, the authors did not note that many well-trained doctors and specialist nurses feel uncomfortable with the mentally ill, as a function of the unpredictable nature of many mental illnesses and the varied manifestations of mental disorders. Patients with mental illness are challenging, and few health care providers truly feel “equipped” to care for them. Mentioning that other health care providers had similar feelings might have normalized the nurses’ responses, letting the rural generalist nurses know that other providers had similar feelings in treating the mentally ill. Ethical Issues A significant ethical milestone was reached when the authors received approval for the project from the Queensland University of Technology University Human Research Ethics Committee and secured ethical approval from the HSD managers (206). However, there are some areas of ethical concern that should be emphasized. If an investigator asks subjects (here, the rural health nurses) to judge and report how “uncomfortable” they are with a certain group of patients, or that “there is nothing I can do” to help a certain group of patients, it is possible the subjects/nurses could become quite distressed, perhaps realizing how “inadequate” they may be in doing a critical aspect of their job. Rural nurses, by design, do not have access to the same support network as those working in urban areas. Given their rural location, they may not have peer or professional support to successfully guide them through their feelings in hopes of returning to a sound professional equilibrium. This is a real, but little-researched topic. When conducting emotionally charged research with subjects who are local or remote, at a minimum it is incumbent upon the researcher to provide information on resources for handling adverse events, including overwhelming emotional responses. Lastly, if a respondent disagreed with virtually every statement, indicating that they strongly did not believe they could appropriately advise patients, that they strongly did not know how to work with the mentally ill, and had no idea how to assess or work with a mentally ill patient in crisis, would the researchers have an ethical obligation to contact the nurse’s supervisor to let them know that the field nurse might not be sufficiently trained to do her job at this time? This becomes an issue when people identify themselves on the survey, but it was not clear from reading Clark et al.’s article if the nurses identified themselves or not. But, considering patient safety and well-being is primary for all in health care, this is not a rhetorical question reserved solely for ethicists. Summary Errors in methodology, design, and written presentation render Clark et al.’s (205-212) article on rural generalist nurses of limited value despite the pressing need for research in the field. 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