|Year : 2020 | Volume
| Issue : 4 | Page : 379-384
Nursing students' knowledge about and attitude toward electroconvulsive therapy: A study from a tertiary care hospital in North India
Bilal Ahmad Bhat, Shabir Ahmad Dar, Arshad Hussain, Rouf Ahmad Mir
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||29-May-2019|
|Date of Decision||22-Aug-2019|
|Date of Acceptance||06-Jan-2020|
|Date of Web Publication||20-Jul-2020|
Bilal Ahmad Bhat
Department of Psychiatry, Government Medical College, Srinagar - 190 003, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Today, electroconvulsive therapy (ECT) has evolved into a modern procedure with a benign side effect profile, which is performed under anesthesia and the administration of muscle relaxants, but the negative view of this treatment is held not only by the general lay public but also by the medical professionals including nurses. Aims: Our aim was to assess the knowledge about and attitude toward ECT in nursing students. Materials and Methods: This was a cross-sectional study in which knowledge about ECT and attitude toward this treatment was assessed in nursing students using ECT knowledge and attitude questionnaires. Statistical analysis was carried out using the Statistical Package for the Social Sciences. Results: A total of 54 3rd-year nursing students were included in the study. More than half (59.3%) reported the primary source of information as media. None of our students had full knowledge about ECT, i.e., score of 31. The mean knowledge score was 16.22 ± 3.36, with a range of 10–21. They were more knowledgeable about the consent, side effects, and procedure part of the questionnaire compared to indications and effectiveness parts of it. Negative attitude toward ECT was highly prevalent. The mean score on attitude questionnaire was −7.5 ± 3.61, with a range of 0 to −12. More than three-quarters of our students had negative attitude in 12 out of 16 items. Total score on knowledge questionnaire and total score on attitude questionnaire were correlated positively (rs= 0.442,P < 0.001). Conclusion: There is a deficiency in knowledge and highly prevalent negative attitude toward ECT among nursing students which needs to be rectified so that ECT becomes a more acceptable treatment procedure.
Keywords: Attitude, electroconvulsive therapy, knowledge, nursing students
|How to cite this article:|
Bhat BA, Dar SA, Hussain A, Mir RA. Nursing students' knowledge about and attitude toward electroconvulsive therapy: A study from a tertiary care hospital in North India. Med J DY Patil Vidyapeeth 2020;13:379-84
|How to cite this URL:|
Bhat BA, Dar SA, Hussain A, Mir RA. Nursing students' knowledge about and attitude toward electroconvulsive therapy: A study from a tertiary care hospital in North India. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Aug 9];13:379-84. Available from: http://www.mjdrdypv.org/text.asp?2020/13/4/379/290159
| Introduction|| |
Electroconvulsive therapy (ECT) has been a safe and effective treatment option for many years now for major psychiatric disorders, including major depression, bipolar affective disorder, and schizophrenia. Today, ECT has evolved into a modern procedure with a benign side effect profile, which is performed under anesthesia and the administration of muscle relaxants. Despite this, negative view of ECT is held not only by the general lay public but also by the medical professionals including nurses. Good amount of research from both developed and developing countries has assessed the knowledge about ECT and attitude toward it among patients and their relatives, and evidence is suggestive of patients receiving ECT being poorly informed about it., In contrast to studies on knowledge and attitude toward ECT in patients and their relatives, the data pertaining to different health-care professionals including medical students, nurses and nursing students, physicians, psychologists, and social workers from developing countries are very limited.,,
Nursing students are going to be future nurses, and owing to the close involvement of nurses with the patients both pre- and post-ECT, the knowledge of and attitude toward ECT of nurses who work in ECT room can have direct impact not only on their quality of nursing practice but also on the patients' and their relatives' knowledge and attitudes toward ECT. There are studies which suggest that nurses and nursing students have a significant poor knowledge and negative attitude toward ECT when compared to medical students. Negative attitude of nurses toward ECT is likely to be reflected negatively in their practice as well. Research suggests that nurses who have negative attitude toward ECT express boredom, apathy, and hostility toward patients who undergo ECT. Further, research also suggests that educating them with brief lectures, educational videotapes, familiarizing with the equipment used for ECT, and observing the ECT procedure can improve the negative attitudes. To understand the baseline knowledge of and attitude toward ECT among nurses and to plan modes to address their poor knowledge and negative attitude, the best suited group to assess would be nursing students who have not witnessed ECT treatment in patients and who have not been to psychiatry rotation before. For this, we aimed to assess the knowledge about and attitude toward ECT in nursing students.
| Materials and Methods|| |
This was a cross-sectional study conducted in Institute of Mental Health and Neurosciences, Kashmir. The approval for this study was given by the institute's Ethics Committee vide their letter IEC/PSY/IMHANS No. 21/2019, dated February 28, 2019. After explaining the nature of the study, written and informed consent was taken from the participants who were recruited from the nursing students undergoing training in Government College for Nursing. All the students were invited to participate in the study at the beginning of their psychiatry rotation. Those students, who have been to psychiatry rotation before, have received ECT as treatment by themselves, have been an attendant to a patient who has received ECT treatment, or do not consent for the study were excluded. After completing sociodemographic details, participating students were required to complete the questionnaire aimed to measure the knowledge and attitude toward ECT treatment. This questionnaire has been used to assess the knowledge and attitude toward ECT treatment previously in Indian studies.,
The knowledge part of the questionnaire covers different aspects of ECT treatment such as the procedure, informed consent, efficacy of this treatment, and side effects of this treatment. In a total of 32 questions in this part, the first item inquires about the primary source of information regarding ECT. In the rest part of this questionnaire, there are three options in every question; one option indicates a correct knowledge, whereas the other option indicates a wrong knowledge. The third option is a response of “don't know” which again indicates lack of knowledge and hence was considered as wrong. To understand the level of knowledge in our students, the correct response to any question from number 2–32 was given a score of “+1” and the wrong response or “don't know” response was given a score of “0.” Accordingly, the total knowledge score could vary from 0 to 31. The second part of this questionnaire specifically looks at the attitude toward ECT and has 16 items. In this part also, there are three possible responses to each item - one response suggesting positive attitude, another response suggesting a negative response, and a third response of “don't know” suggesting a neutral attitude. To calculate the total attitude score, positive response, negative response, and neutral response were rated as “+1,” “−1,” and “0,” respectively.
Statistical analysis was carried out using SPSS version 16 (the Statistical Package for the Social Sciences; IBM Software, NY, USA). Categorical variables were described using frequency and percentage, whereas continuous variables were described as mean and standard deviation. Association between knowledge and attitude was evaluated using Spearman's rank correlation coefficient.
| Results|| |
A total of 54 3rd-year nursing students were included in the study. Females (n = 45; 83.3%) outnumbered males (n = 9; 16.7%). Most of them were from rural background (n = 42; 77.8%) with a small number from urban background (n = 12; 22.2%).
The primary source of information about ECT was assessed in the first item of the knowledge questionnaire. About one-third (n = 19; 35.1%) of our study participants could not give a particular source of information, whereas more than half (n = 32; 59.3%) reported the primary source of information as media (movies, television, and magazines). General word of mouth was source of information in rest (n = 3; 5.6%).
Our students were more knowledgeable about the consent, side effects, and procedure part of the questionnaire compared to other parts of it. The frequencies of correct responses to individual questions are shown in [Table 1]. In the procedure part, more than two-third of our students were aware that anesthetic and other medications are used in ECT (77.8%), current is applied over the head (72.2%), ECT is administered by a psychiatrist/doctor (72.2%), and certain investigations are needed before ECT (72.2%). A number of ECTs required in one course (5.6%) and what ECT actually is (5.6%) were least known to our students. In the consent part, most of them were aware about written permission from patient/family (88.9%). In the indications part, more than half of our students (61.1%) were aware that ECT is not given to only those patients who have little chance of improvement. However, the number of nursing students who were aware of following items was small i.e. for what actually ECT is used (22.2%), ECT can be given to elderly (22.2%) and pregnant women (5.6%) and ECT is not only given to inpatients but can be given to outpatients also (33.3%). In the efficacy of ECT part of our questionnaire, almost all (94.4%) were aware that ECT is useful in treating psychiatric disorders, more than two-third (72.2%) knew that ECT does not result in a permanent cure and scientific evidence favor the usefulness of ECT, more than half (55.6%) knew that ECT does not worsen the psychiatric illness, a little less than a half (44.4%) knew that effects of ECT last only for a short while, and a little less than a quarter (22.2%) knew that ECT is equally or more efficacious than medications. A very small number of our students (5.6%) knew the mechanism how ECT works. In side effects part, almost all our students knew that ECT does not result in permanent damage to the brain (100%) or damage other body parts permanently (94.4). More than two-third of them were aware that ECT neither leads to permanent loss of memory (77.8%) nor is the chances of death very high during the ECT (72.2%). Around half of them were aware that ECT leads to temporary impairment of memory (50%) and headache is a common side effect of ECT (55.6%), whereas around a quarter of them were only aware that patients receiving ECT will not develop epilepsy later (22.2%).
None of our students had full knowledge about ECT, i.e., score of 31. The mean knowledge score was 16.22 ± 3.36, with a range of 10–21.
In [Table 2], it can be seen that on 12 out of 16 items in attitude, more than three-quarters of our students had negative attitude toward ECT, whereas on one item, i.e., “ECT is given indiscriminately to people?,” 61.1% had negative attitude. Only on three items, i.e., “Is ECT an inhumane treatment?; Once a person is given ECT, in future, whenever he/she becomes ill, whether ECT is the only treatment option?; and Does ECT get you better quicker than drugs?,” more than 60% had positive attitude. In ambivalent attitude, the frequency on each item varied from 0% to 16.6%, and there was not a single student who had positive attitude on all the items of the questionnaire.
|Table 2: Attitudes toward electroconvulsive therapy in the study participants (n=54)|
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The mean score on attitude questionnaire was −7.5 ± 3.61, with a range of 0–−12. Majority of these students (n = 51; 94.4%) had total attitude score in the negative range with 24 students (44.4%) having a score of ≥−10. Three students (5.6%) had a score equal to 0. None of them had a score in positive range.
Total score on knowledge questionnaire and total score on attitude questionnaire were correlated positively (Spearman's rank correlation coefficient = 0.442, P < 0.001), indicating that better knowledge was associated with less of negative attitude and vice versa.
| Discussion|| |
ECT as a treatment modality for acute psychotic conditions began in the 1930s, but it was associated with various side effects such as fractures and psychological distress. With the use of anesthesia and muscle relaxants, these side effects were decreased to a great extent, and the mortality rate associated with this treatment is similar to mortality rate of minor surgical procedures in which anesthesia is used., Moreover, ECT has been shown to be effective in patients who do not respond to other treatment modalities including pharmacological treatment. In fact, it has been found to have a quick effect on symptoms of patients than pharmacological treatment.,
Despite positive outcomes, negative and socially undesirable attributes are still associated with it. Although a recent study from Israel on ECT in mental health professionals demonstrated higher knowledge and more positive attitude in nursing staff when compared to social workers and psychologists, a recent study on nursing students from India found poor knowledge and negative attitude toward ECT in them., In our setup, nursing staff is more closely associated with the patients and their relatives as compared to other mental health professionals and thus can potentially influence their knowledge of and attitude toward psychiatric disorders as well as ECT. Therefore, it is very important to understand the knowledge and attitude in nursing staff so as to find any lacuna in their knowledge and attitude. This will help us in understanding the likely areas of intervention to improve their knowledge and attitude which will ultimately reflect as more acceptability of ECT as a treatment by patients and their relatives. The best period to address any deficiency in knowledge of and attitude toward ECT is during the learning phase, and thus, we planned the current study on nursing students. In our study, we found that the nursing students had a good knowledge of consent and a fair knowledge about the procedure and side effects of ECT. There were deficiencies in knowledge about the indications and effectiveness of ECT. A recent similar study on nursing students found that the major areas of deficits in knowledge about ECT were indications, effectiveness, and side effects of ECT.
Negative attitude toward ECT was very common among our students. Only on two items, did our students had a positive attitude in around 70% or more, i.e., “Is ECT an inhuman treatment?” and “Does ECT get you better quicker than drugs?” This is also in consistence with the abovementioned study on nursing students in which it was found that the negative attitude toward ECT is highly prevalent in them. In the absence of uniform tool to assess the knowledge about ECT and attitude toward it, it is difficult to compare the results of the present study with other studies. This comparison is further complicated by different groups which were assessed and are entirely different from our study group such as patients, their relatives, and general public although the negative attitude of nursing students in our study and in all these studies is highly prevalent, nursing students in our study had a better knowledge about ECT.,,
Our findings have important implications as our study participants were those nursing students who were in the 3rd year of their nursing course and still had a deficiency in knowledge and had negative attitude toward ECT. If this deficiency in knowledge and negative attitude toward ECT persists in nurses, this will more likely reinforce ignorance among patients and their relatives. To improve the knowledge and to address the negative attitude in nursing students, there is a need for training and awareness programs. Although psychiatry or mental health is there in curriculum for nursing students, attitude of these nursing students toward psychiatric disorders and different treatment modalities including ECT is ignored. Hence, the burden lies on trainers to evaluate the attitude of these students toward psychiatric disorders and different treatment modalities such as ECT and to address the same and clarify their myths on the basis of scientific evidence. Previous studies have shown that with an increase in knowledge about ECT, there is more of positive attitude toward it.,
In the present study also, though there was highly prevalent negative attitude, there was a positive association between the two with more knowledge associated with less of negative attitude.
Our study should be viewed with certain limitations in mind. Nursing students from a single center were included for this study, and it does not necessarily reflect the knowledge about and attitude toward ECT among nursing students in other colleges. The sample size was also small.
| Conclusion|| |
To conclude our study, we found a deficit in knowledge about ECT among nursing students with highly prevalent negative attitude toward ECT. There is a need to sensitize the trainers to detect these deficiencies and negative attitudes and to rectify any myth with scientific evidence. Further, nursing curriculum should be pro-ECT so that correct information regarding the procedure of ECT, its indications, mechanism of action, etc., is provided to these students. This ultimately will be reflected as more acceptance of this procedure by patients and their relatives.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wilhelmy S, Rolfes V, Grözinger M, Chikere Y, Schöttle S, Groß D. Knowledge and attitudes on electroconvulsive therapy in Germany: A web based survey. Psychiatry Res 2018;262:407-12.
Solomon S, Simiyon M, Vedachalam A. Effectiveness of an educational intervention on medical students' knowledge about and attitude towards electroconvulsive therapy. Acad Psychiatry 2016;40:295-8.
Chakrabarti S, Grover S, Rajagopal R. Perceptions and awareness of electroconvulsive therapy among patients and their families: A review of the research from developing countries. J ECT 2010;26:317-22.
Chakrabarti S, Grover S, Rajagopal R. Electroconvulsive therapy: A review of knowledge, experience and attitudes of patients concerning the treatment. World J Biol Psychiatry 2010;11:525-37.
Oldewening K, Lange RT, Willan S, Strangway C, Kang N, Iverson GL. Effects of an education training program on attitudes to electroconvulsive therapy. J ECT 2007;23:82-8.
Sharma N, Ghai S, Grover S. Knowledge and attitude of nursing students toward electroconvulsive therapy. J Neurosci Rural Pract 2017;8:S7-S12.
Byrne P, Cassidy B, Higgins P. Knowledge and attitudes toward electroconvulsive therapy among health care professionals and students. J ECT 2006;22:133-8.
Lindsay M. Nursing Mirror mental health forum. 2. The ogre of treatment? Nurs Mirror 1983;156:iii, vi.
Rajagopal R, Chakrabarti S, Grover S, Khehra N. Knowledge, experience attitudes concerning electroconvulsive therapy among patients their relatives. Indian J Med Res 2012;135:201-10.
] [Full text]
Tørring N, Sanghani SN, Petrides G, Kellner CH, Østergaard SD. The mortality rate of electroconvulsive therapy: A systematic review and pooled analysis. Acta Psychiatr Scand 2017;135:388-97.
Watts BV, Groft A, Bagian JP, Mills PD. An examination of mortality and other adverse events related to electroconvulsive therapy using a national adverse event report system. J ECT 2011;27:105-8.
UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. Lancet 2003;361:799-808.
Weiner RD, Reti IM. Key updates in the clinical application of electroconvulsive therapy. Int Rev Psychiatry 2017;29:54-62.
Brender R, Dar N, Dannon P. Electroconvulsive therapy: Relating attitude towards treatment and knowledge among mental health professionals in a mental health center. Isr J Psychiatry Relat Sci 2018;55:40-5.
Kawoos Y, Wani ZA, Shah IA, Rather YH, Zarger WA, Amin R. Knowledge and attitude of patients and their relatives towards electro-convulsive therapy: A study from a tertiary care centre in Northern India. Int J Res Med Sci 2017;5:2433.
Grover SK, Chakrabarti S, Khehra N, Rajagopal R. Does the experience of electroconvulsive therapy improve awareness and perceptions of treatment among relatives of patients? J ECT 2011;27:67-72.
Amal I, Alsulami AG, Alfaisal A. Electro convulsive therapy: Impact of an educational program in developing knowledge and attitude of psychiatric nurses working at psychiatric hospital Jeddah. Nurs Health 2015;3:84-9.
Shah ND, Mehta RY, Dave KR. The impact of mental health education on the knowledge and attitude of the peripheral health workers of dang. Natl J Integr Res Med 2015;6: 6-10.
[Table 1], [Table 2]