GLOBAL SHORTAGE OF MENTAL HEALTH NURSES

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RESEARCH APPROACH AND DESIGN

A quantitative approach was viewed appropriate for this study. Quantitative research uses numerical data to obtain information about phenomena, in this case, mental health nursing training in Kenya (Cormack 2000:165; Punch 2006:3).  The design used for the study was exploratory descriptive (Babbie & Mouton 2007:80; Cormack 2000:217). The purpose of the research was to determine the factors associated with choosing mental health nursing as a career and to explore the possible ways of improving recruitment and retention of mental health nurses in Kenya (Burns & Grove 2005:37; Cormack 2000:20; Taylor, Kermode and Roberts 2006:173). Descriptive studies set out to collect, organize and summarize information about the matter being studied, which in this case relate to the mental health nurses (Punch 2006:33). An exploratory approach is known to be sensitive to the specific complexities and emerging issues involved (Lynch & Happell 2008:58). A self administered questionnaire adapted from Happell et al (2008a:531-532) was used to describe the experiences of nurses/students in mental health placement. In addition, focus group discussions, using structured interview schedules yielded rich information regarding career choice (Stommel & Wills 2004:283). The post placement survey/questionnaire yielded quantitative data, making it the paradigm of choice. However, data gathered from the FGD was analyzed qualitatively in order to identify the perceptions of the nurses.

RESEARCH SETTING

The research setting is the environment where the research takes place (Cormack 2000:172). This research was conducted in Nairobi and the area surrounding Nairobi. The setting comprised the main mental hospital and the mental health nursing school in Nairobi, as well as four schools of nursing which are situated within a 100Km range from Nairobi. . There are a total of 68 approved schools of nursing spread all over Kenya. For purposes of this study, only the 4 schools, Kijabe, Machakos, Thika and Murang‟a, which are within a 100kms radius from Nairobi, and which had 4^th year basic students who already had exposure to both theory and practical placement in mental health nursing, were selected. Since the NCK dictates the final examination calendar, it was easy for the researcher to determine the period that the whole group would be in class, and once this was established, arrangements were made to visit the schools to collect the required data.  Since the researcher already obtained permission to conduct the study (see Annexure G), there was no problem in setting specific dates and to obtain entry to the various sites.

POPULATION 

The population is the entire set of individuals having some common characteristics. The accessible population comprises the individuals who conform to the eligibility criteria and are available for a particular study (Burns & Grove 2005:342; Daniel & Longest 1977:37). The population in this study comprised all the fourth year students in the four schools identified as the sample for the study, and who had undergone both theory and clinical placement in mental health nursing, and all the students who are undertaking the diploma in mental health nursing specialization at the Mathari School of Nursing in Nairobi as well as all the practicing registered mental health nurses of Mathari Hospital in Nairobi.

SAMPLE AND SAMPLING

A sample refers to the group of people that a researcher selects from a population, and consists of the individuals about whom the information will be collected. Sampling on the other hand refers to the process by which a sample is selected (Cormack 2000:264, Stommel & Wills 2004:296). Since it is not feasible to include the whole population in the study, a sample that is accessible to the researcher is selected from the study population. There are two types of sampling procedures, namely probability and non-probability sampling. Probability procedures have some form of random sampling while in non-probability sampling there is a lack of random selection procedures (Daniel & Longest 1977: 40, Stommel & Wills 2004: 300). Table 3:1 illustrates the type of sampling method applied in each phase of this study, as well as the applicable sample size.

DATA COLLECTION INSTRUMENTS

A self administered questionnaire was used for data collection from basic nursing students in the four selected nursing schools, and structured interview schedules were used for the focus group discussions.

Self-administered questionnaire

The self-administered questionnaire was adapted from Happell et al (2008a:531 & 532). The Psychiatric/Mental Health Clinical Placement Survey is a brief self report survey to assess student‟s perceived level of preparedness for mental health nursing, their attitudes and beliefs relevant to mental health nursing in general and the degree of satisfaction with clinical experience in particular (Happell et al 2008a: 529). It was chosen because it had been pre-tested and it allowed for the collection of a broader range of data. Happell et al (2008a: 527) used the questionnaire to compare 2 cohorts of second and third year students from the same university in Australia. This post placement survey, administered to students who already had placement in mental health, consists of the following sub scales: the preparation of nurses for the mental health field; their knowledge of mental illness; negative stereotypes; future career options and intended choices; course effectiveness; experience of anxiety surrounding mental illness; valuable contribution and clinical skills of the mentors; and the readiness of students. Participants were asked to respond to a five point Likert scale ranging from strongly agree (5), agree (4), disagree (3), strongly disagree (2), to not sure (1). Self-administered questionnaires have the advantage that many participants can be reached and in addition, they do not involve the interviewer. They are also easy to analyze especially when the responses are standardized. However, the disadvantage is that a misconception is difficult to correct and many questions may go unanswered (Stommel & Wills 2004)

Structured interview schedules (used in FDGs)

 The researcher developed structured interview schedules for the collection of data during the different FGD (Polit & Beck 2006:283). The interview schedules included questions related to attraction/barriers to mental health nursing; career guidance; perceptions regarding mental illness; and suggestions for recruitment and retention. The FGD are well-established qualitative methods of gathering information on a variety of health and policy related issues (Wells et al, 2000:82). It is an exploratory technique for topics about which little is known and the members are chosen because they have some knowledge and/or experience of the subject. The researcher was exploring reasons for the choice of mental health nursing, to gain insight into the student nurses‟ perceptions concerning mental health nursing and mental illness, as well as to gather suggestions for the improvement of the recruitment and retention of nurses in mental health nursing.  The choice of the FGD was therefore most appropriate in this study. One of the main advantages of this method of data collection is that the information obtained is often most valuable for the purposes of the study. However, it does have some limitations, mainly related to the size of the groups, and the possibility that the groups might not be representative (Stommel & Wills 2004:283).

RELIABILITY AND VALIDITY 

Validity and reliability of instruments

Validity measures the truth or accuracy of a claim (Burns and Grove 2005:214). It refers to whether an instrument measures what it intends to measure (Polit & Beck 2008:768). Content validity was verified by a senior faculty member with expertise in health systems research, to ensure it conformed to quality standards (Burns & Grove 2005:219 and 401).  The literature review assisted the researcher to ascertain that the questionnaire contains relevant items to recruitment and retention in mental health nursing for the purposes of the current study.  Content validity refers to adequate representation of items in an instrument to measure a concept (Polit & Beck 2008:750). Content validity for the structured interview schedule was established from the literature review.A measure is said to be reliable if there is consistency. That is, if it gives the same results each time the same situation or factor is measured. A reliable instrument enhances the power of a study to detect significant differences or relationships actually occurring in a population under study (Burns & Grove 2005: 215 and 374). Each item of the sub-scales that were used in the study instrument, such as testing regarding preparation to work in the mental health field; knowledge of mental illness; negative stereotypes; future career opportunities or intentions; course effectiveness; anxiety surrounding mental illness; valuable contributions; clinical skills; and readiness of students were measured with a 5-point scale to indicate frequency of exposure, thereafter responses were dichotomized and summed up. In a paper by Happell et al, the alpha reliability estimate for each of the sub-scales was not indicated in part 2 of the study. However it had been tested in part 1 and a good level of reliability was indicated by a Cronbach‟s Alpha of 0.89 (Happell et al 2008b: 851).  Alpha reliability is expressed in the form of correlation coefficient with 1.00 being perfect reliability.Regarding the focus group discussions, the research team gave adequate notice, had the rooms prepared and the purpose of the study explained in the same way to all the groups, thus ensuring the same conditions for all participants. The discussions were held in a friendly atmosphere, making the participants feel at ease and able to express themselves freely. The interview schedules yielded similar responses from the various groups.

Pre-testing the instruments

The validity of the questionnaire was tested during the pre-test of the instrument using a group of five students based in a school in Nairobi, which is similar to the schools included in the sample. No adjustments were made to the original questionnaire, but two questions were added to provide more clarity regarding career guidance, as this was indicated as being a major theme during the literature review. The results of the literature review also informed the development of the interview schedules. The interview schedules were pre-tested in the Kenyatta National Hospital in Nairobi, using two qualified registered mental health nurses employed by the hospital. During the pre-testing exercise, it became clear that there were several problems with the wording of the questions, such as referring to third parties and not the participants. For example, a question on career attraction was worded as “what attracted them to mental health nursing” instead of “What attracted you to mental health nursing.” The questions were changed accordingly, and were stated in the first person for clarity.

Design Validity

This is mainly a quantitative study, and therefore issues of external validity are very important. External validity measures to what extent the findings can be generalized to other settings or samples (Burns & Grove 2005:218; Cormack 2000:30).  External validity is normally enhanced by means of random sampling and ensuring an adequate sample size to obtain a representative sample. In this study, an adequate sample size was used for the questionnaire group. In addition, the schools and the students who were to participate in the FGD were randomly selected. Rigor was also ensured through method triangulation (Polit & Beck 2006:264) since the researcher used more than one method for data collection.

CHAPTER 1: ORIENTATION TO THE STUDY
1.1    INTRODUCTION
1.2    BACKGROUND INFORMATION
1.3    STATEMENT OF THE RESEARCH PROBLEM
1.4    PURPOSE OF THE STUDY
1.5    OBJECTIVES
1.6    SIGNIFICANCE OF THE STUDY
1.7    DEFINITIONS OF KEY CONCEPTS
1.8    RESEARCH DESIGN AND METHODOLOGY
1.9    ETHICAL CONSIDERATIONS
1.10  OUTLINE OF THE STUDY
CHAPTER 2: THE LITERATURE REVIEW
2.1    INTRODUCTION
2.2    GLOBAL SHORTAGE OF MENTAL HEALTH NURSES
2.3    DATABASES
2.4    RECRUITMENT
2.5    CAREER CHOICE
2.6    TRENDS IN MENTAL HEALTH NURSES TRAINING IN KENYA
2.7    THE SUPPLY AND DEMAND FOR MENTAL HEALTH NURSES
2.8    RETENTION STRATEGIES
2.9    A LOOK INTO THE FUTURE
2.10  CONCLUSION
CHAPTER 3: RESEARCH DESIGN AND METHODOLOGY
3.1    INTRODUCTION
3.2    RESEARCH APPROACH AND DESIGN
3.3    RESEARCH SETTING
3.4    POPULATION
3.5    SAMPLE AND SAMPLING
3.6    DATA COLLECTION INSTRUMENTS
3.7    RELIABILITY AND VALIDITY
3.8    DATA COLLECTION PROCESS
3.9    DATA ANALYSIS
3.10  ETHICAL CONSIDERATIONS
3.11  CONCLUSION
CHAPTER 4: DATA ANALYSIS AND DISCUSSION OF RESEARCH FINDINGS
4.1    INTRODUCTION
4.2    DATA ANALYSIS
4.3    RESEARCH RESULTS
4.4    CONCLUSION
CHAPTER 5: SUMMARY OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS
5.1    INTRODUCTION
5.2    RESEARCH DESIGN AND METHOD
5.3    SUMMARY OF RESEARCH FINDINGS AND CONCLUSIONS
5.4    RECOMMENDATIONS
5.6    CONTRIBUTION OF THE STUDY
5.7    LIMITATIONS OF THE STUDY
5.8    CONCLUDING REMARKS
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CAREER IN MENTAL HEALTH NURSING: THE KENYAN EXPERIENCE