Undergraduate Nursing Students ' Mental Health and Psychiatric Clinical Experience and Their Career Choice in Nursing : Perspectives from the Niger Delta Region of Nigeria

Background: Recruiting young nurses into mental health and psychiatric nursing in Nigeria is difficult and limited. The study aimed to explore undergraduate nursing students' mental health and psychiatric clinical experience and their career choice in nursing. Methods: A cross-sectional survey in classroom settings, using a standardized instrument Attitude towards Psychiatry questionnaire (ATP), explored the attitude of undergraduate nursing students after their mental health/ psychiatric nursing clinical experiences using a chi-square test to compare their positive and negative responses. Results: 122 undergraduate students participated, of whom 90% were female and 10% male, with an overall response rates of 95.6 percent. The majority 59.8% showed positive attitude, while 40.2% showed negative attitude towards psychiatric nursing, indicating that the clinical experience provides positive experiences for some of the participants. Conclusion: Clinical experience in mental health nursing can positively influence perceptions, reduce stigma, and attract nurses to mental health and psychiatric nursing practice. human resource for mental health, specifically psychiatric nurses [11]. Internationally, the shortage of psychiatric nurses is partly attributed to the negative attitudes of nursing students toward mental health disorders, which results in their not considering a career in mental health and psychiatric nursing [12]. A study in Belgium [3] reported that stigma informs nurses professional role constructs and identity and suggest the need to tackle stigma as to motivate nurses to work in mental health care settings. In addition, a study in Australia by Stevens et al. [13]explore career preferences of undergraduate nursing students, comparing their preferences at the start, middle, and end of their Bachelor of Nursing program, and reported that mental health nursing was the least preferred for most of the students. Clinical experience plays an important role in nursing education. A study show that students often enter psychiatric courses with a preconceived image of people with mental illness as dangerous and should be feared [14]. Attitude building of undergraduate nursing students is of utmost importance, as this occurs largely during the period of training [3]. Clinical experience is the bridge by which nursing students becomes familiar with the reality of mental health and prepares them for their professional role, provides opportunities


Introduction
Globally, nurses make up the largest professional group working in the mental health sector, yet a recent analysis of 58 low-and middle in-come countries identified a shortfall of 128,000 per country, this number being needed to provide care for people with mental disorders [1].Interest in the psychiatric profession among undergraduate nursing students has remained low despite, recent developments in care and drug therapy [2,3].The percentage of nursing students pursuing psychiatric nursing practice has declined over the past 20 years, and remains one of the least favoured nursing specialties [4,5].As a result, there is a global shortage of psychiatric nurses, this being more acute in developing countries [6] such as Nigeria, with a ratio of 2.41 per 100:000 people, compared to 10.08 per 100:000 people in South African, also a middle in-come country [7].This has changed little over the years, which suggests that in spite of an increase in the absolute number of psychiatry nurses, the number per unit population has not improved in the country [8].
Mental health disorders refers to a wide range of disorders that affect mood, thinking and behavior [1].Mental health disorders are an important public healthcare issue worldwide, it account for an increasing proportion of the global burden of disease.The World Health Organization (WHO) attributes to these disorders 14% of all of the world's premature deaths and years lived with disability [2].In addition to imposing high costs on the health system, mental health disorders lead to lost worker productivity, impaired functioning, personal stigma, and in some instances, to human rights violations, with current predictions indicating that by 2030, depression will be the leading cause of disease burden globally [1].Research have shown that the general population stigmatizes persons who have been diagnosed with a mental health disorder [9,10].These negative attitudes also occur in mental health professionals, and affect the recruitment of for applying the knowledge, concepts and skills they have learned in classrooms [15][16][17].The ability to choose psychiatric nursing as a career by undergraduate nursing students and their orientation towards management of mental health disorders is important [3].According to Karimollahi [16] a positive relationship with the clinical staff during the experience builds the students' confidence, and increases their satisfaction with the clinical experience.Evidence have shown that the opportunity for students to engage with mental health patients can reduce pre conceived ideas and stigma surrounding mental illness and professional practice [18][19][20].According to Happell, [11] the way in which the theory and practice of mental health and psychiatric nursing is presented to students is of particular importance, especially at a time when recruitment into the profession is proving difficult.It is therefore an important task to ensure good communication and interaction between clinical staff and students in providing a positive clinical experience.In light of the shortage of psychiatric nurses in Nigeria, this study sought to explore undergraduate nursing students 'mental health and psychiatric clinical experience and their career choice in nursing in the Niger Delta region of the country.Understanding perceptions of their clinical experiences will contribute towards addressing them and improving the uptake of this career choice on completion of their training.

Materials and Methods
A pre-test and post-test questionnaire survey in a classroom settings using a standardized instrument Attitude Towards Psychiatry questionnaire (ATP 30), this being designed and validated by Burra et al. [21] in a study on Canadian students, and was modified and used for this study of undergraduate fourth year nursing students.This was done to establish the impact of an eight week mental health and psychiatric nursing clinical experience on their career choice at a tertiary institution in the Niger Delta region of Nigeria.
The study setting was a well-equipped, public sector specialist mental health 50 bedded urban hospital with personnel and resources that provides treatment for all types of mental health disorders, acute or chronic, outpatient and inpatient.The majority of users access the facility directly without referral consultations, with only a few being referred from secondary or tertiary facilities.It serves as both a secondary and tertiary hospital for training students in the health sciences, as well as referral centre, and also renders psychiatric and mental health services for patients in neighboring states who are not able to access them locally.The fourth year undergraduate nursing students, had recently completed a semester course on mental health and psychiatric nursing in the first semester and were required to undertake a eight weeks mental health and psychiatric clinical posting in a mental health facility.The students were required to complete the ATP and after their eight weeks clinical posting and were required to select one of five Likert scale options (Strongly agree, Agree, Neutral, Disagree, and Strongly Disagree) regarding their attitude to each of the questions, mental health disorders and treatment questions, and the effect that these had on selecting a psychiatric nursing career.The questionnaire consisted of two sections on the nurses attitudes, the first dealing with psychiatric/mental health nursing and practice (6 questions), and the second regarding psychiatric treatment and outcome (10 questions).
The results of the Likert scale responses were aggregated per response category and presented as number and percentage.The data was further analyzed using a chi-square test comparing their negative and positive responses using the Statistical Package for Scientific Solutions (SPSS) IBM version 20.Informed consent, confidentiality and anonymity were considered as ethical issues in this study.Ethical approval was provided by the Mental Health Facility Ethics Committee.

Results
Table 1 show results of the 122 fourth year students indicate that 90% were female and 10% male.Almost half (49.2%) were 20-25 years, more than one quarter (27.9%) were 26-30 years of age.The majority were single (70%) and Christian (86.9%). 2 indicate that one third of the students (35.2%) strongly agreed that psychiatric nursing should be excluded as one of the specialties in the undergraduate nursing curriculum, those who agreed in general accounting for 48.3%, a similar number (45.9%) disagreeing to its removal.Over half (55%) strongly agreed that psychiatric nursing was a respectable branch of nursing and a similar number (54.1%) disagree that taking up psychiatric nursing training was synonymous with running away from real nursing practice.Over half (54.9%) strongly disagreed that psychiatric nurses get less job satisfaction than other specialties and 45.1% perceived psychiatric nurses to be as stable as average nurses, while almost two third (61.5%) agreed that psychiatric nursing allows the development of really rewarding relationships.

The findings in Table
Table 3 shows that only half (53.3%) agreed that psychiatric treatment has become more effective in recent years, while 35.9% disagree.Almost two third (61.5%) agreed that the efficacy of psychotropic drugs is sure and a similar number (59%) disagreed that psychotherapy is efficacious.Over half (56.6%) disagree that psychotherapy was fraudulent, but 21.3% still consider this to be the case.The majority (63.1%) agree that patients do improve with psychiatric therapies, although more than half (54.1%) strongly agreed that psychiatric treatments causes patients to be worrisome of their symptoms.A similar number of participants agreed (45.9%) that psychiatrists can do only little for psychiatric patients as disagreed (47.6%).While (54.9%) agreed that psychiatric hospitals were little more than prisons, many (72.2%) agreed that such facilities have specific contributions to make in treating mental disorders.

Variable
No. % Table 4 shows the results of nursing student's perception of psychiatric nursing as a career, indicates that 49 (40.2%) had negative attitude of the specialty, while 73 (59.8%) showed positive attitude towards psychiatric nursing after their clinical experience.

Sex
Table 5 shows students preference for the area of specialization in nursing with the majority (31.1%) noting midwifery, followed by those who are undecided (27.9%).Of the six options, psychiatric nursing was the lowest at 5.7%, this being of concern, considering that they had been exposed to an eight week clinical posting.
Table 6 shows nursing students' perception of psychiatric nursing after their clinical experience.At a 95% confidence interval, the chi square value was 75.342, with a difference of (df) 1, P = 0.000.There was a statistical significant relationship between the students' perception of psychiatric nursing after the clinical posting.

Discussion
The study shows that undergraduate nursing students reflected a positive perception of mental health and psychiatric nursing.The finding is consistent with other studies, [15,16] Happell, [22] reported that nursing student generally have positive attitudes after exposure to mental health and psychiatric clinical experience.Hunter et al. [19] also reported that clinical postings provides valuable experiences for a positive career choice in mental health.Similarly, the study support a recent [5] report of a positive change in student nurses attitudes towards mental illness and mental health nursing on the completion of a clinical placement in mental health.A study by Poreddi et al. [4] confirm that theory and positive clinical experiences in the field of mental health has significant impact on positive change on nursing students' attitudes toward people with mental illness and mental health nursing profession.Evidence has shown that undergraduate nursing programmes provide opportunities to influence nursing students' attitudes with positive clinical experiences in mental health, being identified as having a significant impact on nursing students' attitudes towards people and families living with mental disorders, and mental health nursing as a career [12,16].
The finding reveal that students' perception of psychiatric treatment and outcome shows a considerable improvement in the attitudes during the mental health and psychiatric clinical posting in ten items that addressed different aspects of psychiatric treatment, care provisions and psychiatric facilities in the holistic understanding of treatment outcomes.The majority of the participants appreciates the importance 10. Psychiatric hospitals have specific contributions to make in treatment of mental disorders 49 ( of psychiatry and the effectiveness of treatment, and upheld the fact that psychiatric hospitals are making important contributions towards treating mental health disorders.Similarly, the study of Balhara and Mathur [12] on nursing students attitude towards psychiatry, reported that the study participants held the view that psychiatric research has made good strides in advancing care of major mental health disorders, and that psychiatric treatment is helpful to most people who receive care.In addition, the findings confirms previous evidence that psychiatric treatments has become more effective in recent years with medication, therapy, counselling, social and work place supports, as well as self-care management and general resources for all community members [1,2]. The finding show that nursing students (40.2%) held negative perceptions of mental health disorders and psychiatric nursing practice after their mental health and psychiatric clinical experience.This is similar to a study by Hoekstra et al. [23] on nursing career in mental health care: choices and motives of nursing students which revealed that nursing students have stereotype, mostly negative perceptions of mental health disorders and psychiatric nursing as a career.Another study [19] reported that although few participants agreed that mental health clinical experience prepares them to work as psychiatric nurses, none planned to pursue careers in psychiatric nursing.A study from the region [24] revealed that mental health disorder is regarded as selfinflicted, particularly in conditions of substance/drug use, or that the person and families living with mental disorder is reaping the 'wrath of the gods' for their wicked acts.These beliefs underpins the negative public attitude towards people with the disorder, as well as those of mental health professionals and policy makers towards providing and funding of mental health care services.It has also been reported [10,20] that negative information received from other people is a contributing factor to how mental health professionals and mental health care are perceived.According to Happell et al. [22] nursing students' attitudes are reflective of predominate negative views of the general population.These negative attitudes and perceptions of mental health disorders and mental health care can adversely affect undergraduate nursing students seeking a career in mental health.
Students' preference on area of specialization show that only 5.7% of the participants were willing to pursue psychiatric nursing as a career.The finding is similar to a study by Stevens et al. [13] reported that psychiatric nursing was ranked 8 th , 7 th and 7 th at each time point respectively and showed no statistically significant change over time.Reasons stated for not choosing psychiatric nursing were characterized as negative views of clients, psychiatric institutions and the type of work, negative effect on self-esteem, negative effect of career path and negative experience specific to the course.A study [10] reported that out of 10 specialty areas, psychiatric mental health nursing was ranked last by 122 practicing nurses.In another study [22] of undergraduate nursing students' attitudes towards nursing career choice, it was reported that mental health nursing scored the least.Furthermore, in a three year survey that explored the career preferences of Australian Bachelor of Nursing students for certain clinical specialties by McCann et al. [25] it was reported that first-year students preferred acute care nursing of adults and children, as well as midwifery as a career, but this changed in their third-year to acute care of the adults and mental health.In another study by Dawood [15] revealed a positive perception of psychiatric nursing, but only 13.7% of the participants reported that they would choose psychiatric nursing as a future career, while the majority 86.3% of the participants would not choose psychiatric nursing as a future career.Nurses tend to choose specialties that they perceive as highly skilled or highly valued.There is need to make psychiatric nursing more attractive to motivate nursing students choose psychiatric nursing as their future career.This in turn would assist with recruitment and retention of psychiatric nurses' workforce.

Conclusion
The findings in this study add to other reports about undergraduate nursing students' perceptions of mental health and psychiatric nursing clinical experience and their career choice.The findings suggest that clinical experience in mental health nursing can positively influence perceptions, reduce stigma, and attract nurses to mental health and psychiatric nursing practice.This is one of the least preferred areas of specialty and students' nurses' perception towards mental health disorders and psychiatric nursing practice.Students should be exposed to mental health nursing through clinical experiences, and theory classes, in helping them make informed decision in their eventual career choice.

Limitation of the Study
The study was limited by the small sample size from a single academic institution following an eight week mental health clinical posting.Further studies are suggested to include a larger sample across multiple region with students attending mental health clinical settings.This needs to be accompanied by a qualitative analysis of the reasons for their lack of desire to follow this nursing specialty.

Table 2 :
Nursing student's attitude of mental health/psychiatric nursing and practice.

Table 3 :
Nursing students perception of psychiatric treatment and outcomes.

Table 4 :
Nursing Students attitude of psychiatric nursing as a career.

Table 5 :
Students preference on area of specialization in nursing.

Table 6 :
Nursing Students Perception of Psychiatric nursing clinical experience.