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post evaluation of a module of study
Nurse Education Today 36 (2016) 364–369
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Impact of perinatal mental health education on student midwives' knowledge, skills and attitudes: A pre/post evaluation of a module of study Agnes Higgins ⁎, Margaret Carroll, Danika Sharek School of Nursing and Midwifery, Trinity College Dublin, Ireland
a r t i c l e
i n f o
Article history: Accepted 10 September 2015 Editor: W. Lauder Keywords: Perinatal Mental health Midwife education Midwives Evaluation
s u m m a r y Background: Whilst midwives are well-placed to identify and address the mental health need of women in their care, many report lacking the ability to do so. Therefore, they ignore or brush aside women's mental health needs. To improve midwives' competency in this area, the first authors developed and delivered a module on perinatal mental health issues within their university. The module aimed to improve knowledge, skills, and attitudes in relation to working with women about mental health issues. In 2012, a post-survey evaluation of the module demonstrated positive findings; following a number of revisions to the module, this more robust pre/post evaluation was conducted. Objectives: The objective of this study was to examine the impact of the perinatal mental health module on student midwives' knowledge, skills, and attitudes in addressing mental health issues with women. Design Pre-module and Post-module Surveys were Used. Participants: Participants were students undertaking a 4-year undergraduate direct entry midwifery degree programme in Ireland. The pre-survey had 28 participants, the post-survey had 26 participants, and there were 25 matched pairs. Methods: The data were analysed using SPSS Version 21.0. Descriptive, frequencies and paired sample t-tests were calculated. Qualitative data were analysed thematically. Results: Comparison of the pre and post measures, based on paired samples t-tests, showed that the programme statistically increased participants' knowledge and skills. Whilst students' self-reported attitudes towards women and mental health issues were already quite positive, they reported even more positive attitudes following the course. Written feedback provided by students also supported these positive findings. Conclusion: This evaluation provides evidence that a module on perinatal mental health is effective at improving the self-reported knowledge, skills, and attitudes of student midwives towards women with mental health issues. It is recommended that educators consider the opportunity of including a similar module in their curriculum. © 2015 Elsevier Ltd. All rights reserved.
Introduction Midwives are well-placed to address mental health issues with women by conducting assessments, providing information, and supporting them in making informed choices about care and treatment. Many midwives, however, feel that they lack the competency and education to support women with mental health care, which can lead to these needs being ignored or brushed aside. Therefore, the first two named authors developed and delivered a module on perinatal mental health issues for the undergraduate direct entry midwifery programme within their university. The module aimed to enhance knowledge and skills in talking to women about mental health issues and to assist them in identifying and responding to mental health issues in an ⁎ Corresponding author. E-mail address: [email protected] (A. Higgins).
http://dx.doi.org/10.1016/j.nedt.2015.09.007 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
appropriate manner. In 2012, a post-survey evaluation of the module demonstrated positive findings whilst making suggestions for improvement (Higgins et al, 2012). Following on from this evaluation, a number of revisions were made to the module content and assessment and a more robust pre/post evaluation of the impact of these changes on the knowledge, skills and attitudes of the midwifery students taking the module was undertaken. The aim of this paper is to report on findings from this evaluation. Background/literature Mental health problems among pregnant women are a leading indirect cause of maternal morbidity and mortality, with a significant number of women dying by suicide during pregnancy and in the postnatal period (Centre for Maternal and Child Enquires (CMACE), 2011). It is estimated that 15–25% of women will develop a mental health problem
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either during pregnancy or the first year post pregnancy (National Institute for Clinical Excellence, 2007). These may range from anxiety and depression during or after pregnancy to more extreme forms of distress, such as psychosis. Midwives play a vital role in the maintenance of positive health for both the expectant mother and child. Therefore, topics such as mental health problems, factors contributing to mental health problems, impact of mental health problems, available resources, as well as skills to assess, support and provide appropriate referrals for women should be of extreme importance to midwifery practice. Whilst the vast majority of midwives encounter women with, or at risk of developing, perinatal mental health problems (PMHP), most research indicates that midwives lack the knowledge and skills to be able to effectively and comprehensively assess and support women's mental health; research has also found that midwives lack awareness and confidence in referring women to appropriate resources (Stewart and Henshaw, 2002; Ross-Davie et al., 2006; Mivsek et al, 2008; McCauley et al, 2011). This lack of competence can result in undiagnosed problems, which, in turn, can have seriously negative consequences for women in their care, including relapse of existing mental health problem, development of new problems, and in the extreme case, maternal suicide (CMACE, 2011). PMHP during pregnancy can also impact negatively on the foetus and are associated with an increased risk of pre-term delivery and growth retardation (Ding et al, 2014; Kim et al, 2013). McCauley et al.'s (2011) study of midwives in Australia found that whilst the midwives recognised that they were indeed caring for women with, or at risk of developing, mental health problems, they reported having received little or no education in mental health and, more alarmingly, they did not perceive assessment of mental health needs as an important aspect of their role, perceiving it to be the role of other professionals (McCauley et al, 2011). Similarly, Slovenian midwives and nurses reported significant knowledge deficits with some considering that it is the doctor's role to detect postnatal depression (Skočir and Hundley, 2006; Mivsek et al, 2008). The majority of midwives (n = 266) in Stewart and Henshaw's (2002) UK study identified the correct prevalence of ‘baby blues’ and psychosis but was more likely to underestimate the prevalence for both antenatal and postnatal depression. In addition, they did not feel that they had the necessary knowledge or skills, including listening and counselling, to meet the needs of women. Similarly, Buist et al. (2006) study found that whilst health care professionals, including midwives and GPs (n = 1153) were aware and knowledgeable of PMHP, they required further education on antenatal depression and the use of non-pharmacological methods for treating depression. In a recent study of soon to be qualified midwives, Jarrett (2015) reported that students felt ill-prepared and lacked confidence to care for women, underestimated the risks of women with existing mental health problems developing a serious mental health problem during pregnancy, and relied on intuitive practice as opposed to screening tools or other standardised tools or questions to assess women's mental health experiences. In addition to lacking knowledge, some studies suggest that midwives, including student midwives, may be stigmatising women with mental health problems, perceiving them to be difficult to care for, unable to parent effectively and at risk of harming their babies, others or themselves (McCauley et al, 2011; Jarrett, 2014). In most studies, midwives express their motivation to enhance their knowledge and skills. Whilst women who experienced mental health problems during pregnancy or in the post natal period are critical of midwives for their failure to respond to their emotional needs in an informed, empathetic and timely manner, they view midwives as important sources of information and support (Begley et al., 2010; Feeley et al, 2015). Perinatal Mental Health Module A 30 hour module was designed to develop the knowledge and skill of midwifery students in relation to perinatal mental health care. It was
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delivered to a group of students undertaking an undergraduate direct entry midwifery degree programme. Emphasis within the module was on enabling students to develop the knowledge and confidence to talk to women about mental health issues during the prenatal and postnatal in a timely and empathetic manner. Emphasis was also on reassuring the students that they did not have to be skilled in cognitive or psychoanalytic therapy to achieve positive outcomes, but that women's mental health could be positively impacted through: education of women and their partners on perinatal mental health; early identification of women who are at increased risks of developing a perinatal mental health problem; giving women space to discuss their worries and concerns about mothering, including past experiences of mental health problems; affirming women as mothers; offering women opportunities to talk about their birth experience; giving practical support and information, such as providing information on self-care strategies and support groups; and providing opportunities for women to be able to sleep and rest during the postnatal period. A more in-depth discussion of the aims, learning outcomes and pedagogical approaches underpinning this module has been described elsewhere (Higgins et al, 2012). Objective The objective of this study was to examine the impact of participation in the module on student midwives' knowledge, skills and attitudes in addressing mental health issues with women. Methods A repeated measure survey design was used; participants completed the survey both before the module began and after completing the module. The surveys were designed with reference to the literature evaluating midwives knowledge, attitude and confidence in supporting women with mental health problems (Ross-Davie et al., 2006; Jones et al, 2012). Measures The pre-survey comprised close-ended questions, mostly 5-point Likert scale, which asked questions in four main areas: demographics, knowledge, skill, and attitudes. In the demographics section, students were asked to identify their gender, age, and if they had any self-experience of mental health problems. In the knowledge section, respondents were asked to rate their knowledge on a 5 point scale (1 = poor to 5 = excellent) in relation to 16 mental health items. The third section requested respondents to rate their perceived skill, defined as ability and confidence, to respond to 22 scenarios on a 5-point scale (1 = poor to 5 = excellent). In the fourth and final section, respondents were asked to rate their attitudes towards five statements about women and mothers who experience mental health issues, with high scores indicating more negative attitudes. The post-survey was comprised of the same close-ended questions, along with three openended questions, asking the students to describe things they liked about the module, changes they would like to see made to the module, and any additional comments. Recruitment and Informed Consent Participants were third year students undertaking a 4-year undergraduate direct entry midwifery degree programme in Ireland. All those who participated (n = 28) in the module were invited to participate in the evaluation. The purpose of the survey was explained by two of the authors (AH & MC). The voluntary nature of participation was emphasised and it was explained clearly that non-participation would have no effect on the students' marks in the module. Furthermore, the anonymous nature of the survey was explained to the students and they were provided with the opportunity to ask any questions on the
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evaluation. Students were reminded and advised not to put their name on the survey and, instead, they were asked to choose a unique identifier so that their pre/post surveys could be matched for the purpose of analysis. Paper copy surveys were distributed to students prior to commencing the module and again at the end of the module. Students could return survey immediately in envelope provided or at a later time.
Data Analysis Data were entered into SPSS Version 21.0 and statistically analysed. Descriptives and frequencies were generated for all items. In order to test for statistical significance, each participant was given an overall score on the knowledge topics (16 items) and skill topics (22 items) both pre and post module. Both of the scales had good to excellent levels of internal consistency (Knowledge: Cronbach's α = .747; Skills: Cronbach's α = .910). A series of paired samples t-tests were conducted to examine changes in knowledge, skills, and attitudes from pre to post module. These tests only included the 25 matched pairs. Statistical significance was set at .05 for the overall scales and at .01 for each individual item in the scale.
Results Demographics Of the 28 students invited to be involved all (n = 28, 100%) responded to the pre-survey and 26 (93%) to the post-survey; although it should be noted that not every student answered every question. Given the high response rate no reminders were sent to students. All of the participants were female. The age ranges were between 19 and 54, with the majority of participants between 19 and 24 years of age. Participants were asked about their experience of mental health problems. About half of the students in both the pre (53%; n = 15) and post survey (50%; n = 13) reported that they had a family member who has a mental health problem. Over 80% in both pre (86%; n = 24) and post (81%; n = 21) reported that they knew someone who had a mental health problem. 25% (n = 7) of participants in the presurvey reported that they themselves had experienced a mental health problem. However, this increased to 31% (n = 8) in the post survey. Whilst this may appear to be greater that the WHO (2011) statistics of 1 in 4 people experiencing a mental health at some time in their lives, it may be also be that the participants were declaring episodes of mental
distress as opposed to mental health issues that received a diagnosis or required professional interventions. Impact of Programme on Knowledge Participants were asked to rate their pre and post knowledge on 16 topics, including: mental health problems (depression, anxiety, eating disorders, psychosis); impact of mental health problems; to screening tools; support services; and the Mental Health Act. There was a statistically significant increase in total self-rated knowledge from pre to postsurvey. The overall mean score for participants pre course was 1.59 (SD = .24) and this increased to 2.60 (SD = .24) post course. A paired sample t-test of the overall pre and post means yielded statistically significant results [t (24) = −18.29, p = b.001]. There were also statistically significant increases in knowledge for every topic (see Table 1). In the pre-survey, the majority of students reported poor (4%–75%) or fair/good (14%–79%) knowledge on the topics. The topics participants reported having the poorest knowledge were on: the use of psychotropic drugs in pregnancy whilst breastfeeding (86%); maternal morbidity in relation to mental health problems (75%); suicide in pregnancy and postnatal period (75%); the Mental Health Act (71%); and the impact of maternal mental health problems on the baby (68%). The exception was postnatal depression, where 36% (n = 10) of participants reporting very good/excellent knowledge in this area. In the post-survey, clear improvements could be seen with only one participant (4%) reporting poor knowledge in any of the areas (‘use of psychotropic drugs in pregnancy whilst breastfeeding’). The number of those reporting very good/ excellent knowledge rose to 25% to 96% in all of the areas, with 60% or more of the students reporting very good/excellent knowledge in 9 of the 16 topics. Impact of the Programme on Skills Participants were asked to rate their pre and post skill level in 22 areas that focused on various dimensions of communication, including: asking women questions about mental health issues; providing information to women; responding to women's questions; and responding to women who have unusual thoughts or beliefs. There was a statistically significant increase in total self-rated skills from pre to post-survey. The overall mean score for participants pre course was 1.65 (SD = .28) and this increased to 2.47 (SD = .28) post course. A paired sample t-test of the overall pre and post means yielded statistically significant results [t (24) = − 12.96, p = b .001]. In addition, there were
Table 1 Changes in mean knowledge from pre to post module. Knowledge in relation to …
Pre M (SD)
Post M (SD)
t-Test
Risk factors for developing mental health in perinatal period Antenatal depression Postnatal depression Antenatal anxiety Postnatal anxiety Obsessive thinking Screening tools for perinatal mental health problems Eating disorder and pregnancy Psychosis in perinatal period Bipolar affective disorder Use of psychotropic drugs in pregnancy and whilst breastfeeding Maternal morbidity in relation to mental health problems Impact of maternal mental health problems on the baby Suicide in pregnancy and postnatal period Support services for women with mental health problems Mental Health Act Knowledge: self-rated total score
1.96 (.46) 1.68 (.48) 2.36 (.57) 1.64 (.49) 1.96 (.61) 1.72 (.61) 1.52 (.51) 1.48 (.59) 1.49 (.51) 1.83 (.58) 1.12 (.33) 1.20 (.41) 1.32 (.48) 1.20 (.41) 1.64 (.57) 1.32 (.48) 1.59 (.24)
2.96 (.20) 2.64 (.49) 2.96 (.20) 2.40 (.50) 2.72 (.46) 2.56 (.51) 2.48 (.51) 2.64 (.49) 2.65 (.49) 2.61 (.50) 2.32 (.56) 2.48 (.51) 2.32 (.48) 2.6 (.50) 2.68 (.48) 2.64 (.49) 2.60 (.24)⁎
t (24) = −10.00⁎⁎⁎ t (24) = −8.91⁎⁎⁎ t (24) = −5.20⁎⁎⁎ t (24) = −5.73⁎⁎⁎ t (24) = −5.73⁎⁎⁎ t (24) = −5.63⁎⁎⁎ t (24) = −7.86⁎⁎⁎ t (24) = −8.43⁎⁎⁎ t (22) = −7.85⁎⁎⁎ t (22) = −5.59⁎⁎⁎ t (24) = −8.49⁎⁎⁎ t (24) = −9.44⁎⁎⁎ t (24) = −8.66⁎⁎⁎ t (24) = −14.00⁎⁎⁎ t (24) = −6.59⁎⁎⁎ t (24) = −10.52⁎⁎⁎ t (24) = −18.29⁎⁎⁎
⁎⁎⁎ p b .01.
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Table 2 Changes in skills from pre to post module. Skills in relation to …
Pre M (SD)
Post M (SD)
t-Test
Asking a woman about previous mental health problems at booking visit Supporting women who are tearful at antenatal clinic Supporting women who are tearful postnatal Supporting women who are anxious at an antenatal visit Supporting women who are anxious postnatal Talking to women about pre-existing mental health problems Talking to women about depression Talking to women about psychosis Talking to women about obsessive thinking Talking to women about eating disorders Talking to women about psychotropic medication Talking to women about completing the Edinburgh Depression Scale Explaining to women the risk of depression in the perinatal period Explaining to women the risks of psychosis in the perinatal period Assessing women about suicide risk Asking women about alcohol use Asking women about drug misuse Asking women about domestic violence Asking women about sexual abuse Responding to a woman who thinks her baby is not hers, possessed by evil spirits Responding to a woman who ask about taking psychotropic medication during pregnancy Responding to a woman who asks about taking psychotropic medication whilst breastfeeding Skills: total score
2.00 (.50) 2.16 (.47) 2.28 (.46) 2.08 (.40) 2.16 (.37) 1.83 (.57) 1.92 (.64) 1.32 (.48) 1.32 (.48) 1.50 (.72) 1.21 (.42) 1.76 (.60) 2.00 (.58) 1.40 (.50) 1.21 (.42) 1.72 (.54) 1.72 (.54) 1.68 (.56) 1.54 (.59) 1.17 (.48) 1.16 (.37) 1.20 (.41) 1.65 (.28)
2.56 (.51) 2.76 (.44) 2.92 (.28) 2.68 (.48) 2.84 (.37) 2.63 (.50) 2.64 (.49) 2.32 (.48) 2.32 (.48) 2.42 (.50) 2.21 (.42) 2.68 (.48) 2.72 (.46) 2.40 (.50) 2.04 (.55) 2.56 (.51) 2.52 (.51) 2.36 (.49) 2.25 (.53) 2.04 (.62) 2.16 (.37) 2.20 (.41) 2.47 (.28)
t (24) = −4.03⁎⁎⁎ t (24) = −5.20⁎⁎⁎ t (24) = −6.53⁎⁎⁎ t (24) = −5.20⁎⁎⁎ t (24) = −7.14⁎⁎⁎ t (23) = −5.38⁎⁎⁎ t (24) = −5.31⁎⁎⁎ t (24) = −7.75⁎⁎⁎ t (24) = −8.66⁎⁎⁎ t (23) = −6.87⁎⁎⁎ t (23) = −8.31⁎⁎⁎ t (24) = −8.05⁎⁎⁎ t (24) = −7.86⁎⁎⁎ t (24) = −7.07⁎⁎⁎ t (23) = −6.41⁎⁎⁎ t (24) = −6.11⁎⁎⁎ t (24) = −5.66⁎⁎⁎ t (24) = −4.54⁎⁎⁎ t (23) = −5.03⁎⁎⁎ t (23) = −7.00⁎⁎⁎ t (24) = −10.00⁎⁎⁎ t (24) = −8.66⁎⁎⁎ t (24) = −12.96⁎⁎⁎
⁎⁎⁎ p b .01.
statistically significant increases in every skill areas (see Table 2). In the pre-survey, no more than 25% of respondents reported very/good excellent skills in any of the areas. The areas in which the students reported having the poorest skills were:
the areas identified and these included: asking women about sexual abuse (4%); assessing women's suicide risk (12%); and responding to a woman who thinks her baby is not hers, possessed by evil spirits (16).
• responding to a woman who thinks her baby is not hers, possessed by evil spirits (86%); • responding to a woman who asks about taking psychotropic medication during pregnancy (82%); • responding to a woman who asks about taking psychotropic medication whilst breastfeeding (79%); • talking to a woman about psychotropic medication (79%); • assessing women about suicide risk (79%); • talk to women about psychosis (68%); • talking to women with obsessive thinking (68%); and • talking to women about eating disorders (64%).
Impact of Programme on Attitudes
In the post-survey, clear improvements could be seen with 50% of more of the students reporting very good/excellent skills In 11 of the 22 areas. Only a handful of participants reported poor skill in any of
Participants were asked to rate the views on 5 attitude statements. Whilst the overall mean score for participants decreased from 1.42 (SD = .48) to 1.24 (SD = .33), a paired sample t-test of the overall pre and post means did not yielded any statistically significant differences in attitudes pre and post survey (Table 3). This is likely due to the fact that in the pre-surveys, participants already had very positive self-reported attitudes towards women with mental health problems, with low mean scores. In the pre-survey, very high proportions (89%– 96%) of students disagreed with the negative statements, meaning they did not hold negative views towards women with mental health issues. Less than 7% of students were neutral on any of the statements, and only one student agreed with one statement ‘Women who have a mental health problem shouldn't have the same rights to have children as other women.’ In the post survey, the students' attitudes became
Table 3 Changes in attitudes from pre to post module. Please rate the following items on a scale from 1 (you strongly disagree) to 5 (you strongly agree):
Pre Disagree % (n)
Neither agree nor disagree % (n)
Post
One of the main reasons women experience mental illness is a lack of self-discipline and will power (n = 28, 26) Once women show signs of mental disturbances they should be hospitalized (n = 28, 26) There is something about women with mental illness that makes it easy to tell them from ‘normal’ women (n = 28, 26) Women who have a mental health problem shouldn't have the same rights to have children as other women (n = 28, 26) Women who have mental health problems make poor mothers (n = 28, 26) Attitudes: total score
93% (26)
7% (2)
100% (26)
93% (26)
7% (2)
100% (26)
96% (27)
4% (1)
89% (25)
7% (2)
96% (27)
4% (1)
96% (25) 96% (25) 100% (26)
Pre M (SD)/post M (SD) 1.42 (.48)/1.24 (.33)
Agree % (n)
4% (1)
Disagree % (n)
Neither agree nor disagree % (n)
Agree % (n)
4% (1)
t-Test: t (24) = 1.739, p = .095
4% (1)
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even more positive as nearly all of the students disagreed with every negative attitude statement. Impact of Experience of Mental Health Problems on Outcomes It was hypothesised that those who had more experience with a mental health problem, e.g., those who reported they had a family member, knew someone, or they themselves had a mental health problem, would report greater knowledge and skills within the survey. Independent samples t-test was run to compare overall scores on the Knowledge and Skills scales (both pre and post) for the three subgroups. No statistically significant differences were found. Students' Reported Satisfaction and View of the Module Overall the students were very satisfied with both the course content and teaching strategies. All of the students either agreed or strongly agreed with the statement that ‘The module content was applicable to my clinical practice’ and 93% of students agreed or strongly agreed that the content was interesting. Many students added qualitative comments (see Table 4) which supported the quantitative findings, and clearly indicated that the module helped them to open their mind to the lived experience of women who experience mental distress and gave them greater confidence for practice. When asked about changes that they would like to see made to the module, most of the students answered in a positive manner, stating that the module was satisfactory and did not require change. When students did make suggestions they were focused on the need to incorporate more ‘role-play’, ‘discussion’, and ‘working in groups’ to assist them develop more confidence in responding to women. Discussion Midwives are in an ideal position to supports women by: providing emotional support to women during pregnancy, birth and the postnatal period; conducting timely and appropriate mental health assessments; providing women with information on mental health promotion and mental health problems; and assisting women in making appropriate and informed choices around treatment options and services available (reference to be inserted post-review). Evidence suggests, however, that in many cases, midwives lack education, confidence and skills, with authors calling for more education and skill development in these areas (Buist et al., 2006; Mivsek et al., 2008; Işik and Bilgili, 2010, Jones et al. 2010, Jarrett, 2014, 2015). The purpose of the study was to assess the effectiveness of a module on perinatal mental health aimed at improving care for women who may experience mental health issues. In particular, the effects of the module on knowledge, skills and attitudes were examined. Students' opinions about the module were also elicited with particular emphasis on satisfaction and improvements required. This more robust evaluation strategy builds on previous
findings (Higgins et al, 2012) providing statistically significant evidence that a module on perinatal mental health positively impacts on students' knowledge and skills. Whilst students' self-reported attitudes towards women and mental health issues were already quite positive, they reported even more positive attitudes following the course. Although it was hypothesised that those who had more experience with a mental health problem, e.g., those who reported they had a family member, knew someone, or they themselves had a mental health problem, would report greater knowledge and skills in this survey, this was found to not be the case. All students appeared to improve equally across the knowledge and skills scales. Other studies demonstrate evidence of positive outcomes of education in this area or perinatal mental health; however, these education programmes tend to be focused on qualified midwives or health visitors and on the topic of postnatal depression and screening tools to assess depression with a lack of emphasis on other issues such as psychosis, anxiety and depression during pregnancy (Gerrard et al, 1993; Ross-Davie et al, 2007; Jardri et al., 2010),. Notwithstanding the importance of post natal depression, to provide competent care midwives need to be versed in other mental health issues, such as those included in the module in this study, namely psychosis, anxiety, eating disorders, bipolar disorders, depression during pregnancy, suicide and the use of psychotropic medication. Educating midwives and student midwives in these issues is critical, given the risk associated with a diagnosis of bipolar disorder and schizophrenia and postnatal psychosis (NICE 2007), women's criticisms of the ‘conspiracy of silence’ around other mental health issues, especially psychosis in prenatal education (Begley et al, 2010; Teeffelen et al, 2011), and lack of knowledge and confidence among student midwives about severe mental health problems, particularly schizophrenia, bipolar disorder and psychosis (Jarrett, 2015). Participants provided useful suggestions for building on the outcomes in future education programmes, such as the inclusion of role play. The inclusion of role play and opportunity for rehearsal in a safe space is necessary to build students' confidence to raise and discuss what is often perceived as very sensitive issues, such as sexual abuse, suicide and unusual beliefs or ‘delusions’. Whilst high levels of skill deficits were reported in these area prior to the module, only a handful of participants in the post-survey reporting poor skill in ‘asking women about sexual abuse’ (4%), ‘assessing women's suicide risk’ (12%), and ‘responding to a woman who thinks her baby is not hers, possessed by evil spirits’ (16%). Some of these areas were mentioned by students in the qualitative comments as requiring more practice using ‘safe’ simulated role plays. Developing confidence and skill in raising and discussing these issues with women is a process that requires practice within and outside the classroom; therefore, focusing solely on education within the classroom is not likely to have a long-term impact, as students also need space and time to discuss issues in the real world of practice and engage in the self, theoretical and relational reflection necessary to be comfortable discussing these issues. Given the possible absence of effective role modelling in practice, educators also need to
Table 4 Students' comments on the module. Content interesting and informative Enhanced confidence
Being less judgemental and enhanced understanding
Recommendations
“I found the content very interesting and helpful as mental health issues are not discussed or taught to me in the clinical setting.” “Content was very interesting and informative” “I would be more confident now at recognising signs of Antenatal and Postnatal Depression” “Content will guide my professional practice in the future as well as giving me some personal insight.” “It made me less concerned about raising certain issues [with women]. It has also made me think more about the women I am dealing with.” “It helped me open up more towards people with mental health. Gave me an understanding of what people with mental health go through” “The focus on the woman, not condemning her or making her out to be an unfit parent but truly focusing on her health and best interests. The focus on not stigmatising.” “It would make me less concerned about raising certain issues. It has also made me less judgemental and think more about who you are dealing with.” “Maybe to have more practice in dealing one on one with a woman experiencing mental health problems eg, doing more role play situation to try to build experience.” “More role play on how to talk about things like suicide” “More emphasis on what we can actually do for the women on the wards with antenatal and postnatal depression, more practice”
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continue to provide in-service education to qualified midwives so that they can act as effective role models and clinical mentors and support students midwives to develop the necessary competence to raise mental health issues with women. In the authors' view, the focus of education needs initially to be on demystifying mental distress and medical diagnostic language, which frequently stigmatises women and creates a barrier to midwives preventing them from using their engagement skills of presence, positivity, encouragement, compassion and empathy, which are part of the everyday practice of the skilled reflective midwife (MacLellan, 2011; Higgins et al, 2012). Only then should the focus move to the more ‘technical’ aspects of mental health assessment, screening, referral skills and skills in working with women who experience severe mental distress. At all times, it should be remembered that midwives are being education to differentiate between women who are experiencing distress which may resolve with support from the midwife and women who are at risk of experiencing more severe distress which requires referral to mental health practitioners or specialist perinatal mental health teams. Given the increased demand on practitioners' time and the difficulties in getting released for continuing professional development, the development of blended learning approaches as described by Larkin et al (2015) is worthy of consideration. Only with a concerted effort to educate at pre- and post-registration level will midwives of the future be able to provide truly holistic care to women, as the barriers to providing care to all women who experience mental health difficulties are removed. Study Limitations There are a number of limitations to this study including the small number of participants involved. In addition, it is that it is not possible to state with certainty that the changes are indeed education effects, as there was no control group with which to compare. It seems unlikely, however, that a group of students who nearly all reported low levels of knowledge and skills would show spontaneous, simultaneous changes. The reliance on self-reporting may have introduced a bias, with students wishing to present more favourably on their increase in knowledge and skills. Finally, the study only captured students reported outcomes, so there is no way of knowing if the knowledge and skills were transferable to practice. Conclusion Whilst further studies would benefit from the development of pretests and post-tests to measure knowledge, and skill rather than relying on self-reporting, this evaluation provides evidence that a module on perinatal mental health is effective at improving the self-reported knowledge, and skills of student midwives. It is recommended that educators consider the opportunity of including a similar module in their own preregistration curriculum. It is also recommended that follow up studies include measures of midwives' interactions with women to assess the application and transferability of the knowledge and skills gained into the practice context. Funding This study received no funding.
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Acknowledgements The authors would like to thank the students who completed the survey and took their time to provide feedback on the module. References Begley, C., Higgins, A., Lalor, J., Sheerin, F., Alexander, J., Nicholl, H., Lawler, D., Keenan, P., Tuohy, T., Kavanagh, R., 2010. The Strengths and Weaknesses of Publicly-funded Irish Health Services Provided to Women With Disabilities in Relation to Pregnancy, Childbirth and Early Motherhood. National Disability Authority, Dublin. Buist, A., Bilszta, J., Milgrom, J., Barnett, B., Hayes, B., Austin, M.P., 2006. Health professional's knowledge and awareness of perinatal depression: results of a national survey. Women Birth 19 (1), 11–16. Centre for Maternal, Child Enquires, 2011. Saving mothers' lives: reviewing maternal deaths to make motherhood safer: 2006–2008. the eighth report of the confidential enquiries into maternal deaths in the United Kingdom British. J. Obstet. Gynaecol. 118 (Suppl. 1), 1–203 (http://www.centreformidwiferyeducation.ie/wp-content/ uploads/2011/03/CMACE-2011-Saving-Mothers-Lives-Reviewing-maternal-deathsto-make-motherhood-safer-2006-2008.pdf Accessed 15th February 2015). Ding, X., LeWu, Y., JunXu, S., PingZhu, R., MinJia, X., FenZhang, S., KunHuang, PengZhu, Jia-HuHao, and Fang-BiaoTao, 2014. Maternal anxiety during pregnancy and adverse birth outcomes: a systematic review and meta-analysis of prospective cohort studies. J. Affect. Disord. 159 (20), 103–110. Feeley, N., Bell, L., Hayton, B., Zelkowitz, P., Carrier, M., 2015. Care for postpartum depression: what do women and their partners prefer? Perspect. Psychiatr. Care 1–11. http://dx.doi.org/10.1111/ppc.12107. Gerrard, J., Holden, J., Elliott, S., McKenzie, P., McKenzie, J., Cox, J.L., 1993. A trainer's perspective of an innovative programme teaching health visitors about the detection, treatment and prevention of post natal depression. J. Adv. Nurs. 18 (11), 1825–1832. Higgins, A., Carroll, M., Sharek, D., 2012. It opened my mind: student midwives' views of a motherhood and mental health module. MIDIRS Midwifery Dig. 2 (3), 287–292. Işik, S.N., Bilgili, N., 2010. Postnatal depression: midwives and nurses' knowledge and practices. Erciyes Med. J. 32 (4), 265–274. Jardri, R., Maron, M., Pelta, J., Thomas, P., Codaccioni, X., Goudemand, M., Delion, P., 2010. Impact of midwives' training on postnatal depression on screening in the first week post delivery: a quality improvement report. Midwifery 26 (6), 622–629. Jarrett, P., 2014. Attitudes of student midwives caring for women with perinatal mental health problems. Br. J. Midwifery 22 (10), 718–724. Jarrett, P., 2015. Student midwives' knowledge of perinatal mental health. Br. J. Midwifery 23 (1), 32–39. Jones, C.J., Creedy, D.K., Gamble, J.A., 2010. Australian midwives' attitudes towards care for women with emotional distress. Midwifery (Epublication). Jones, C.J., Creedy, D.K., Gamble, J.A., 2012. Australian midwives' awareness and management of antenatal and postpartum depression. Women and Birth 25 (1), 23–28. Kim, D., Socklor, L., Sammel, M., Kelly, C., Moseley, M., Epperson, C., 2013. Elevated risk of adverse obstetric outcomes in pregnant women with depression. Arch. Womens Ment. Health 16 (6), 475–482. Larkin, V., Flaherty, A., Keyes, C., Yasseen, J., 2015. Exploring maternal perinatal mental health using a blended learning package. Br. J. Midwifery 22 (3), 210–217. MacLellan, J., 2011. The art of midwifery practice: a discourse analysis. MIDIRS 21 (1), 25–31. McCauley, K., Elsom, S., Muir-Cochrane, E., Lyneham, J., 2011. Midwives and assessment of perinatal mental health. J. Psychiatr. Ment. Health Nurs. 18 (9), 786–795. Mivsek, A.P., Hindley, V., Kiger, A., 2008. Slovenian midwives' and nurses' views on postnatal depression: an exploratory study. Int. Nurs. Rev. 55 (3), 320–326. National Institute for Health and Clinical Excellence, 2007. Antenatal and Postnatal Mental Health Clinical Guidelines. National Institute for Health and Clinical Excellence, London. Ross-Davie, M., Elliott, S., Green, L., 2007. Planning and implementing mental health training. Br. J. Midwifery 15 (4), 199–203. Ross-Davie, M., Elliott, S., Sarkar, A., Green, L., 2006. A public health role in perinatal mental health: are midwives ready? Br. J. Midwifery 14 (6), 330–334. Skočir, A.P., Hundley, V., 2006. Are Slovenian midwives and nurses ready to take on a greater role in caring for women with postnatal depression? Midwifery 22 (1), 40–55. Steward, C., Henshaw, C., 2002. Midwives and perinatal mental health. Br. J. Midwifery 10 (2), 117–121. Teeffelen, A.S., Nieuwenhuijze, M., Korstjens, I., 2011. Women want proactive psychosocial support from midwives during transition to motherhood: a qualitative study. Midwifery 27 (1), 122–127. World Health Organisation, 2011. Mental Health Atlas 2011. www.who.int/entity/mental_ health/publications/mental_health_atlas_2011/en/-29k (Accessed 14 January 2015).
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Impact of perinatal mental health education on student midwives' knowledge, skills and attitudes: A pre/post evaluation of a module of study Agnes Higgins ⁎, Margaret Carroll, Danika Sharek School of Nursing and Midwifery, Trinity College Dublin, Ireland
a r t i c l e
i n f o
Article history: Accepted 10 September 2015 Editor: W. Lauder Keywords: Perinatal Mental health Midwife education Midwives Evaluation
s u m m a r y Background: Whilst midwives are well-placed to identify and address the mental health need of women in their care, many report lacking the ability to do so. Therefore, they ignore or brush aside women's mental health needs. To improve midwives' competency in this area, the first authors developed and delivered a module on perinatal mental health issues within their university. The module aimed to improve knowledge, skills, and attitudes in relation to working with women about mental health issues. In 2012, a post-survey evaluation of the module demonstrated positive findings; following a number of revisions to the module, this more robust pre/post evaluation was conducted. Objectives: The objective of this study was to examine the impact of the perinatal mental health module on student midwives' knowledge, skills, and attitudes in addressing mental health issues with women. Design Pre-module and Post-module Surveys were Used. Participants: Participants were students undertaking a 4-year undergraduate direct entry midwifery degree programme in Ireland. The pre-survey had 28 participants, the post-survey had 26 participants, and there were 25 matched pairs. Methods: The data were analysed using SPSS Version 21.0. Descriptive, frequencies and paired sample t-tests were calculated. Qualitative data were analysed thematically. Results: Comparison of the pre and post measures, based on paired samples t-tests, showed that the programme statistically increased participants' knowledge and skills. Whilst students' self-reported attitudes towards women and mental health issues were already quite positive, they reported even more positive attitudes following the course. Written feedback provided by students also supported these positive findings. Conclusion: This evaluation provides evidence that a module on perinatal mental health is effective at improving the self-reported knowledge, skills, and attitudes of student midwives towards women with mental health issues. It is recommended that educators consider the opportunity of including a similar module in their curriculum. © 2015 Elsevier Ltd. All rights reserved.
Introduction Midwives are well-placed to address mental health issues with women by conducting assessments, providing information, and supporting them in making informed choices about care and treatment. Many midwives, however, feel that they lack the competency and education to support women with mental health care, which can lead to these needs being ignored or brushed aside. Therefore, the first two named authors developed and delivered a module on perinatal mental health issues for the undergraduate direct entry midwifery programme within their university. The module aimed to enhance knowledge and skills in talking to women about mental health issues and to assist them in identifying and responding to mental health issues in an ⁎ Corresponding author. E-mail address: [email protected] (A. Higgins).
http://dx.doi.org/10.1016/j.nedt.2015.09.007 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
appropriate manner. In 2012, a post-survey evaluation of the module demonstrated positive findings whilst making suggestions for improvement (Higgins et al, 2012). Following on from this evaluation, a number of revisions were made to the module content and assessment and a more robust pre/post evaluation of the impact of these changes on the knowledge, skills and attitudes of the midwifery students taking the module was undertaken. The aim of this paper is to report on findings from this evaluation. Background/literature Mental health problems among pregnant women are a leading indirect cause of maternal morbidity and mortality, with a significant number of women dying by suicide during pregnancy and in the postnatal period (Centre for Maternal and Child Enquires (CMACE), 2011). It is estimated that 15–25% of women will develop a mental health problem
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either during pregnancy or the first year post pregnancy (National Institute for Clinical Excellence, 2007). These may range from anxiety and depression during or after pregnancy to more extreme forms of distress, such as psychosis. Midwives play a vital role in the maintenance of positive health for both the expectant mother and child. Therefore, topics such as mental health problems, factors contributing to mental health problems, impact of mental health problems, available resources, as well as skills to assess, support and provide appropriate referrals for women should be of extreme importance to midwifery practice. Whilst the vast majority of midwives encounter women with, or at risk of developing, perinatal mental health problems (PMHP), most research indicates that midwives lack the knowledge and skills to be able to effectively and comprehensively assess and support women's mental health; research has also found that midwives lack awareness and confidence in referring women to appropriate resources (Stewart and Henshaw, 2002; Ross-Davie et al., 2006; Mivsek et al, 2008; McCauley et al, 2011). This lack of competence can result in undiagnosed problems, which, in turn, can have seriously negative consequences for women in their care, including relapse of existing mental health problem, development of new problems, and in the extreme case, maternal suicide (CMACE, 2011). PMHP during pregnancy can also impact negatively on the foetus and are associated with an increased risk of pre-term delivery and growth retardation (Ding et al, 2014; Kim et al, 2013). McCauley et al.'s (2011) study of midwives in Australia found that whilst the midwives recognised that they were indeed caring for women with, or at risk of developing, mental health problems, they reported having received little or no education in mental health and, more alarmingly, they did not perceive assessment of mental health needs as an important aspect of their role, perceiving it to be the role of other professionals (McCauley et al, 2011). Similarly, Slovenian midwives and nurses reported significant knowledge deficits with some considering that it is the doctor's role to detect postnatal depression (Skočir and Hundley, 2006; Mivsek et al, 2008). The majority of midwives (n = 266) in Stewart and Henshaw's (2002) UK study identified the correct prevalence of ‘baby blues’ and psychosis but was more likely to underestimate the prevalence for both antenatal and postnatal depression. In addition, they did not feel that they had the necessary knowledge or skills, including listening and counselling, to meet the needs of women. Similarly, Buist et al. (2006) study found that whilst health care professionals, including midwives and GPs (n = 1153) were aware and knowledgeable of PMHP, they required further education on antenatal depression and the use of non-pharmacological methods for treating depression. In a recent study of soon to be qualified midwives, Jarrett (2015) reported that students felt ill-prepared and lacked confidence to care for women, underestimated the risks of women with existing mental health problems developing a serious mental health problem during pregnancy, and relied on intuitive practice as opposed to screening tools or other standardised tools or questions to assess women's mental health experiences. In addition to lacking knowledge, some studies suggest that midwives, including student midwives, may be stigmatising women with mental health problems, perceiving them to be difficult to care for, unable to parent effectively and at risk of harming their babies, others or themselves (McCauley et al, 2011; Jarrett, 2014). In most studies, midwives express their motivation to enhance their knowledge and skills. Whilst women who experienced mental health problems during pregnancy or in the post natal period are critical of midwives for their failure to respond to their emotional needs in an informed, empathetic and timely manner, they view midwives as important sources of information and support (Begley et al., 2010; Feeley et al, 2015). Perinatal Mental Health Module A 30 hour module was designed to develop the knowledge and skill of midwifery students in relation to perinatal mental health care. It was
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delivered to a group of students undertaking an undergraduate direct entry midwifery degree programme. Emphasis within the module was on enabling students to develop the knowledge and confidence to talk to women about mental health issues during the prenatal and postnatal in a timely and empathetic manner. Emphasis was also on reassuring the students that they did not have to be skilled in cognitive or psychoanalytic therapy to achieve positive outcomes, but that women's mental health could be positively impacted through: education of women and their partners on perinatal mental health; early identification of women who are at increased risks of developing a perinatal mental health problem; giving women space to discuss their worries and concerns about mothering, including past experiences of mental health problems; affirming women as mothers; offering women opportunities to talk about their birth experience; giving practical support and information, such as providing information on self-care strategies and support groups; and providing opportunities for women to be able to sleep and rest during the postnatal period. A more in-depth discussion of the aims, learning outcomes and pedagogical approaches underpinning this module has been described elsewhere (Higgins et al, 2012). Objective The objective of this study was to examine the impact of participation in the module on student midwives' knowledge, skills and attitudes in addressing mental health issues with women. Methods A repeated measure survey design was used; participants completed the survey both before the module began and after completing the module. The surveys were designed with reference to the literature evaluating midwives knowledge, attitude and confidence in supporting women with mental health problems (Ross-Davie et al., 2006; Jones et al, 2012). Measures The pre-survey comprised close-ended questions, mostly 5-point Likert scale, which asked questions in four main areas: demographics, knowledge, skill, and attitudes. In the demographics section, students were asked to identify their gender, age, and if they had any self-experience of mental health problems. In the knowledge section, respondents were asked to rate their knowledge on a 5 point scale (1 = poor to 5 = excellent) in relation to 16 mental health items. The third section requested respondents to rate their perceived skill, defined as ability and confidence, to respond to 22 scenarios on a 5-point scale (1 = poor to 5 = excellent). In the fourth and final section, respondents were asked to rate their attitudes towards five statements about women and mothers who experience mental health issues, with high scores indicating more negative attitudes. The post-survey was comprised of the same close-ended questions, along with three openended questions, asking the students to describe things they liked about the module, changes they would like to see made to the module, and any additional comments. Recruitment and Informed Consent Participants were third year students undertaking a 4-year undergraduate direct entry midwifery degree programme in Ireland. All those who participated (n = 28) in the module were invited to participate in the evaluation. The purpose of the survey was explained by two of the authors (AH & MC). The voluntary nature of participation was emphasised and it was explained clearly that non-participation would have no effect on the students' marks in the module. Furthermore, the anonymous nature of the survey was explained to the students and they were provided with the opportunity to ask any questions on the
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evaluation. Students were reminded and advised not to put their name on the survey and, instead, they were asked to choose a unique identifier so that their pre/post surveys could be matched for the purpose of analysis. Paper copy surveys were distributed to students prior to commencing the module and again at the end of the module. Students could return survey immediately in envelope provided or at a later time.
Data Analysis Data were entered into SPSS Version 21.0 and statistically analysed. Descriptives and frequencies were generated for all items. In order to test for statistical significance, each participant was given an overall score on the knowledge topics (16 items) and skill topics (22 items) both pre and post module. Both of the scales had good to excellent levels of internal consistency (Knowledge: Cronbach's α = .747; Skills: Cronbach's α = .910). A series of paired samples t-tests were conducted to examine changes in knowledge, skills, and attitudes from pre to post module. These tests only included the 25 matched pairs. Statistical significance was set at .05 for the overall scales and at .01 for each individual item in the scale.
Results Demographics Of the 28 students invited to be involved all (n = 28, 100%) responded to the pre-survey and 26 (93%) to the post-survey; although it should be noted that not every student answered every question. Given the high response rate no reminders were sent to students. All of the participants were female. The age ranges were between 19 and 54, with the majority of participants between 19 and 24 years of age. Participants were asked about their experience of mental health problems. About half of the students in both the pre (53%; n = 15) and post survey (50%; n = 13) reported that they had a family member who has a mental health problem. Over 80% in both pre (86%; n = 24) and post (81%; n = 21) reported that they knew someone who had a mental health problem. 25% (n = 7) of participants in the presurvey reported that they themselves had experienced a mental health problem. However, this increased to 31% (n = 8) in the post survey. Whilst this may appear to be greater that the WHO (2011) statistics of 1 in 4 people experiencing a mental health at some time in their lives, it may be also be that the participants were declaring episodes of mental
distress as opposed to mental health issues that received a diagnosis or required professional interventions. Impact of Programme on Knowledge Participants were asked to rate their pre and post knowledge on 16 topics, including: mental health problems (depression, anxiety, eating disorders, psychosis); impact of mental health problems; to screening tools; support services; and the Mental Health Act. There was a statistically significant increase in total self-rated knowledge from pre to postsurvey. The overall mean score for participants pre course was 1.59 (SD = .24) and this increased to 2.60 (SD = .24) post course. A paired sample t-test of the overall pre and post means yielded statistically significant results [t (24) = −18.29, p = b.001]. There were also statistically significant increases in knowledge for every topic (see Table 1). In the pre-survey, the majority of students reported poor (4%–75%) or fair/good (14%–79%) knowledge on the topics. The topics participants reported having the poorest knowledge were on: the use of psychotropic drugs in pregnancy whilst breastfeeding (86%); maternal morbidity in relation to mental health problems (75%); suicide in pregnancy and postnatal period (75%); the Mental Health Act (71%); and the impact of maternal mental health problems on the baby (68%). The exception was postnatal depression, where 36% (n = 10) of participants reporting very good/excellent knowledge in this area. In the post-survey, clear improvements could be seen with only one participant (4%) reporting poor knowledge in any of the areas (‘use of psychotropic drugs in pregnancy whilst breastfeeding’). The number of those reporting very good/ excellent knowledge rose to 25% to 96% in all of the areas, with 60% or more of the students reporting very good/excellent knowledge in 9 of the 16 topics. Impact of the Programme on Skills Participants were asked to rate their pre and post skill level in 22 areas that focused on various dimensions of communication, including: asking women questions about mental health issues; providing information to women; responding to women's questions; and responding to women who have unusual thoughts or beliefs. There was a statistically significant increase in total self-rated skills from pre to post-survey. The overall mean score for participants pre course was 1.65 (SD = .28) and this increased to 2.47 (SD = .28) post course. A paired sample t-test of the overall pre and post means yielded statistically significant results [t (24) = − 12.96, p = b .001]. In addition, there were
Table 1 Changes in mean knowledge from pre to post module. Knowledge in relation to …
Pre M (SD)
Post M (SD)
t-Test
Risk factors for developing mental health in perinatal period Antenatal depression Postnatal depression Antenatal anxiety Postnatal anxiety Obsessive thinking Screening tools for perinatal mental health problems Eating disorder and pregnancy Psychosis in perinatal period Bipolar affective disorder Use of psychotropic drugs in pregnancy and whilst breastfeeding Maternal morbidity in relation to mental health problems Impact of maternal mental health problems on the baby Suicide in pregnancy and postnatal period Support services for women with mental health problems Mental Health Act Knowledge: self-rated total score
1.96 (.46) 1.68 (.48) 2.36 (.57) 1.64 (.49) 1.96 (.61) 1.72 (.61) 1.52 (.51) 1.48 (.59) 1.49 (.51) 1.83 (.58) 1.12 (.33) 1.20 (.41) 1.32 (.48) 1.20 (.41) 1.64 (.57) 1.32 (.48) 1.59 (.24)
2.96 (.20) 2.64 (.49) 2.96 (.20) 2.40 (.50) 2.72 (.46) 2.56 (.51) 2.48 (.51) 2.64 (.49) 2.65 (.49) 2.61 (.50) 2.32 (.56) 2.48 (.51) 2.32 (.48) 2.6 (.50) 2.68 (.48) 2.64 (.49) 2.60 (.24)⁎
t (24) = −10.00⁎⁎⁎ t (24) = −8.91⁎⁎⁎ t (24) = −5.20⁎⁎⁎ t (24) = −5.73⁎⁎⁎ t (24) = −5.73⁎⁎⁎ t (24) = −5.63⁎⁎⁎ t (24) = −7.86⁎⁎⁎ t (24) = −8.43⁎⁎⁎ t (22) = −7.85⁎⁎⁎ t (22) = −5.59⁎⁎⁎ t (24) = −8.49⁎⁎⁎ t (24) = −9.44⁎⁎⁎ t (24) = −8.66⁎⁎⁎ t (24) = −14.00⁎⁎⁎ t (24) = −6.59⁎⁎⁎ t (24) = −10.52⁎⁎⁎ t (24) = −18.29⁎⁎⁎
⁎⁎⁎ p b .01.
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Table 2 Changes in skills from pre to post module. Skills in relation to …
Pre M (SD)
Post M (SD)
t-Test
Asking a woman about previous mental health problems at booking visit Supporting women who are tearful at antenatal clinic Supporting women who are tearful postnatal Supporting women who are anxious at an antenatal visit Supporting women who are anxious postnatal Talking to women about pre-existing mental health problems Talking to women about depression Talking to women about psychosis Talking to women about obsessive thinking Talking to women about eating disorders Talking to women about psychotropic medication Talking to women about completing the Edinburgh Depression Scale Explaining to women the risk of depression in the perinatal period Explaining to women the risks of psychosis in the perinatal period Assessing women about suicide risk Asking women about alcohol use Asking women about drug misuse Asking women about domestic violence Asking women about sexual abuse Responding to a woman who thinks her baby is not hers, possessed by evil spirits Responding to a woman who ask about taking psychotropic medication during pregnancy Responding to a woman who asks about taking psychotropic medication whilst breastfeeding Skills: total score
2.00 (.50) 2.16 (.47) 2.28 (.46) 2.08 (.40) 2.16 (.37) 1.83 (.57) 1.92 (.64) 1.32 (.48) 1.32 (.48) 1.50 (.72) 1.21 (.42) 1.76 (.60) 2.00 (.58) 1.40 (.50) 1.21 (.42) 1.72 (.54) 1.72 (.54) 1.68 (.56) 1.54 (.59) 1.17 (.48) 1.16 (.37) 1.20 (.41) 1.65 (.28)
2.56 (.51) 2.76 (.44) 2.92 (.28) 2.68 (.48) 2.84 (.37) 2.63 (.50) 2.64 (.49) 2.32 (.48) 2.32 (.48) 2.42 (.50) 2.21 (.42) 2.68 (.48) 2.72 (.46) 2.40 (.50) 2.04 (.55) 2.56 (.51) 2.52 (.51) 2.36 (.49) 2.25 (.53) 2.04 (.62) 2.16 (.37) 2.20 (.41) 2.47 (.28)
t (24) = −4.03⁎⁎⁎ t (24) = −5.20⁎⁎⁎ t (24) = −6.53⁎⁎⁎ t (24) = −5.20⁎⁎⁎ t (24) = −7.14⁎⁎⁎ t (23) = −5.38⁎⁎⁎ t (24) = −5.31⁎⁎⁎ t (24) = −7.75⁎⁎⁎ t (24) = −8.66⁎⁎⁎ t (23) = −6.87⁎⁎⁎ t (23) = −8.31⁎⁎⁎ t (24) = −8.05⁎⁎⁎ t (24) = −7.86⁎⁎⁎ t (24) = −7.07⁎⁎⁎ t (23) = −6.41⁎⁎⁎ t (24) = −6.11⁎⁎⁎ t (24) = −5.66⁎⁎⁎ t (24) = −4.54⁎⁎⁎ t (23) = −5.03⁎⁎⁎ t (23) = −7.00⁎⁎⁎ t (24) = −10.00⁎⁎⁎ t (24) = −8.66⁎⁎⁎ t (24) = −12.96⁎⁎⁎
⁎⁎⁎ p b .01.
statistically significant increases in every skill areas (see Table 2). In the pre-survey, no more than 25% of respondents reported very/good excellent skills in any of the areas. The areas in which the students reported having the poorest skills were:
the areas identified and these included: asking women about sexual abuse (4%); assessing women's suicide risk (12%); and responding to a woman who thinks her baby is not hers, possessed by evil spirits (16).
• responding to a woman who thinks her baby is not hers, possessed by evil spirits (86%); • responding to a woman who asks about taking psychotropic medication during pregnancy (82%); • responding to a woman who asks about taking psychotropic medication whilst breastfeeding (79%); • talking to a woman about psychotropic medication (79%); • assessing women about suicide risk (79%); • talk to women about psychosis (68%); • talking to women with obsessive thinking (68%); and • talking to women about eating disorders (64%).
Impact of Programme on Attitudes
In the post-survey, clear improvements could be seen with 50% of more of the students reporting very good/excellent skills In 11 of the 22 areas. Only a handful of participants reported poor skill in any of
Participants were asked to rate the views on 5 attitude statements. Whilst the overall mean score for participants decreased from 1.42 (SD = .48) to 1.24 (SD = .33), a paired sample t-test of the overall pre and post means did not yielded any statistically significant differences in attitudes pre and post survey (Table 3). This is likely due to the fact that in the pre-surveys, participants already had very positive self-reported attitudes towards women with mental health problems, with low mean scores. In the pre-survey, very high proportions (89%– 96%) of students disagreed with the negative statements, meaning they did not hold negative views towards women with mental health issues. Less than 7% of students were neutral on any of the statements, and only one student agreed with one statement ‘Women who have a mental health problem shouldn't have the same rights to have children as other women.’ In the post survey, the students' attitudes became
Table 3 Changes in attitudes from pre to post module. Please rate the following items on a scale from 1 (you strongly disagree) to 5 (you strongly agree):
Pre Disagree % (n)
Neither agree nor disagree % (n)
Post
One of the main reasons women experience mental illness is a lack of self-discipline and will power (n = 28, 26) Once women show signs of mental disturbances they should be hospitalized (n = 28, 26) There is something about women with mental illness that makes it easy to tell them from ‘normal’ women (n = 28, 26) Women who have a mental health problem shouldn't have the same rights to have children as other women (n = 28, 26) Women who have mental health problems make poor mothers (n = 28, 26) Attitudes: total score
93% (26)
7% (2)
100% (26)
93% (26)
7% (2)
100% (26)
96% (27)
4% (1)
89% (25)
7% (2)
96% (27)
4% (1)
96% (25) 96% (25) 100% (26)
Pre M (SD)/post M (SD) 1.42 (.48)/1.24 (.33)
Agree % (n)
4% (1)
Disagree % (n)
Neither agree nor disagree % (n)
Agree % (n)
4% (1)
t-Test: t (24) = 1.739, p = .095
4% (1)
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even more positive as nearly all of the students disagreed with every negative attitude statement. Impact of Experience of Mental Health Problems on Outcomes It was hypothesised that those who had more experience with a mental health problem, e.g., those who reported they had a family member, knew someone, or they themselves had a mental health problem, would report greater knowledge and skills within the survey. Independent samples t-test was run to compare overall scores on the Knowledge and Skills scales (both pre and post) for the three subgroups. No statistically significant differences were found. Students' Reported Satisfaction and View of the Module Overall the students were very satisfied with both the course content and teaching strategies. All of the students either agreed or strongly agreed with the statement that ‘The module content was applicable to my clinical practice’ and 93% of students agreed or strongly agreed that the content was interesting. Many students added qualitative comments (see Table 4) which supported the quantitative findings, and clearly indicated that the module helped them to open their mind to the lived experience of women who experience mental distress and gave them greater confidence for practice. When asked about changes that they would like to see made to the module, most of the students answered in a positive manner, stating that the module was satisfactory and did not require change. When students did make suggestions they were focused on the need to incorporate more ‘role-play’, ‘discussion’, and ‘working in groups’ to assist them develop more confidence in responding to women. Discussion Midwives are in an ideal position to supports women by: providing emotional support to women during pregnancy, birth and the postnatal period; conducting timely and appropriate mental health assessments; providing women with information on mental health promotion and mental health problems; and assisting women in making appropriate and informed choices around treatment options and services available (reference to be inserted post-review). Evidence suggests, however, that in many cases, midwives lack education, confidence and skills, with authors calling for more education and skill development in these areas (Buist et al., 2006; Mivsek et al., 2008; Işik and Bilgili, 2010, Jones et al. 2010, Jarrett, 2014, 2015). The purpose of the study was to assess the effectiveness of a module on perinatal mental health aimed at improving care for women who may experience mental health issues. In particular, the effects of the module on knowledge, skills and attitudes were examined. Students' opinions about the module were also elicited with particular emphasis on satisfaction and improvements required. This more robust evaluation strategy builds on previous
findings (Higgins et al, 2012) providing statistically significant evidence that a module on perinatal mental health positively impacts on students' knowledge and skills. Whilst students' self-reported attitudes towards women and mental health issues were already quite positive, they reported even more positive attitudes following the course. Although it was hypothesised that those who had more experience with a mental health problem, e.g., those who reported they had a family member, knew someone, or they themselves had a mental health problem, would report greater knowledge and skills in this survey, this was found to not be the case. All students appeared to improve equally across the knowledge and skills scales. Other studies demonstrate evidence of positive outcomes of education in this area or perinatal mental health; however, these education programmes tend to be focused on qualified midwives or health visitors and on the topic of postnatal depression and screening tools to assess depression with a lack of emphasis on other issues such as psychosis, anxiety and depression during pregnancy (Gerrard et al, 1993; Ross-Davie et al, 2007; Jardri et al., 2010),. Notwithstanding the importance of post natal depression, to provide competent care midwives need to be versed in other mental health issues, such as those included in the module in this study, namely psychosis, anxiety, eating disorders, bipolar disorders, depression during pregnancy, suicide and the use of psychotropic medication. Educating midwives and student midwives in these issues is critical, given the risk associated with a diagnosis of bipolar disorder and schizophrenia and postnatal psychosis (NICE 2007), women's criticisms of the ‘conspiracy of silence’ around other mental health issues, especially psychosis in prenatal education (Begley et al, 2010; Teeffelen et al, 2011), and lack of knowledge and confidence among student midwives about severe mental health problems, particularly schizophrenia, bipolar disorder and psychosis (Jarrett, 2015). Participants provided useful suggestions for building on the outcomes in future education programmes, such as the inclusion of role play. The inclusion of role play and opportunity for rehearsal in a safe space is necessary to build students' confidence to raise and discuss what is often perceived as very sensitive issues, such as sexual abuse, suicide and unusual beliefs or ‘delusions’. Whilst high levels of skill deficits were reported in these area prior to the module, only a handful of participants in the post-survey reporting poor skill in ‘asking women about sexual abuse’ (4%), ‘assessing women's suicide risk’ (12%), and ‘responding to a woman who thinks her baby is not hers, possessed by evil spirits’ (16%). Some of these areas were mentioned by students in the qualitative comments as requiring more practice using ‘safe’ simulated role plays. Developing confidence and skill in raising and discussing these issues with women is a process that requires practice within and outside the classroom; therefore, focusing solely on education within the classroom is not likely to have a long-term impact, as students also need space and time to discuss issues in the real world of practice and engage in the self, theoretical and relational reflection necessary to be comfortable discussing these issues. Given the possible absence of effective role modelling in practice, educators also need to
Table 4 Students' comments on the module. Content interesting and informative Enhanced confidence
Being less judgemental and enhanced understanding
Recommendations
“I found the content very interesting and helpful as mental health issues are not discussed or taught to me in the clinical setting.” “Content was very interesting and informative” “I would be more confident now at recognising signs of Antenatal and Postnatal Depression” “Content will guide my professional practice in the future as well as giving me some personal insight.” “It made me less concerned about raising certain issues [with women]. It has also made me think more about the women I am dealing with.” “It helped me open up more towards people with mental health. Gave me an understanding of what people with mental health go through” “The focus on the woman, not condemning her or making her out to be an unfit parent but truly focusing on her health and best interests. The focus on not stigmatising.” “It would make me less concerned about raising certain issues. It has also made me less judgemental and think more about who you are dealing with.” “Maybe to have more practice in dealing one on one with a woman experiencing mental health problems eg, doing more role play situation to try to build experience.” “More role play on how to talk about things like suicide” “More emphasis on what we can actually do for the women on the wards with antenatal and postnatal depression, more practice”
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continue to provide in-service education to qualified midwives so that they can act as effective role models and clinical mentors and support students midwives to develop the necessary competence to raise mental health issues with women. In the authors' view, the focus of education needs initially to be on demystifying mental distress and medical diagnostic language, which frequently stigmatises women and creates a barrier to midwives preventing them from using their engagement skills of presence, positivity, encouragement, compassion and empathy, which are part of the everyday practice of the skilled reflective midwife (MacLellan, 2011; Higgins et al, 2012). Only then should the focus move to the more ‘technical’ aspects of mental health assessment, screening, referral skills and skills in working with women who experience severe mental distress. At all times, it should be remembered that midwives are being education to differentiate between women who are experiencing distress which may resolve with support from the midwife and women who are at risk of experiencing more severe distress which requires referral to mental health practitioners or specialist perinatal mental health teams. Given the increased demand on practitioners' time and the difficulties in getting released for continuing professional development, the development of blended learning approaches as described by Larkin et al (2015) is worthy of consideration. Only with a concerted effort to educate at pre- and post-registration level will midwives of the future be able to provide truly holistic care to women, as the barriers to providing care to all women who experience mental health difficulties are removed. Study Limitations There are a number of limitations to this study including the small number of participants involved. In addition, it is that it is not possible to state with certainty that the changes are indeed education effects, as there was no control group with which to compare. It seems unlikely, however, that a group of students who nearly all reported low levels of knowledge and skills would show spontaneous, simultaneous changes. The reliance on self-reporting may have introduced a bias, with students wishing to present more favourably on their increase in knowledge and skills. Finally, the study only captured students reported outcomes, so there is no way of knowing if the knowledge and skills were transferable to practice. Conclusion Whilst further studies would benefit from the development of pretests and post-tests to measure knowledge, and skill rather than relying on self-reporting, this evaluation provides evidence that a module on perinatal mental health is effective at improving the self-reported knowledge, and skills of student midwives. It is recommended that educators consider the opportunity of including a similar module in their own preregistration curriculum. It is also recommended that follow up studies include measures of midwives' interactions with women to assess the application and transferability of the knowledge and skills gained into the practice context. Funding This study received no funding.
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