Knowledge and Attitudes of Advanced Practice Nursing Students Towards Depression

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A Thesis

Presented to the faculty of the School of Nursing California State University, San Marcos

Submitted in partial satisfaction of the requirements for the degree of

MASTER OF SCIENCE

in

Nursing Family Nurse Practitioner

by Karen Adams

SPRING

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©2015

Karen Adams

ALL RIGHTS RESERVED

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THESIS

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THESIS CO

THESIS SUBMlTTED IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

MASTER OF SCIENCE

IN

NURSING

THESIS TITLE: Knowledge and Attitudes of Advanced Practice Nursing Students Towards

Depression

AUTHOR: Karen Adams

DATE OF SUCCESSFUL DEFENSE:

THE THESIS HAS BEEN ACCEPTED BY THE THESIS COMMITTEE IN

PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE TN NURSING.

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, Graduate Coordinator

Denise Boren Director Date

is suitable for shelving in the Library and credit is to be awarded for the thesis.

School ofNursing

College of Education, Health, and Human Services California State University San Marcos

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Towards Depression by Karen Adams Statement of Problem

Advanced Practice Nursing students do not have appropriate knowledge and attitudes to manage depression. There have been no previous studies that have looked specifically at the knowledge and

attitudes of advanced practice nursing student's towards depression, prior to graduation. Current research

focuses primarily on the knowledge and attitudes of I icensed Nurse Practitioners and Physicians, and their

comfort level with managing depression. Sources of Data

The sample subjects are registered nurses enrolled in one of four Nurse Practitioner programs: 1 ). CSUSM Family Nurse Practitioner, 2) Psychiatric Nurse Practitioner, 3). SDSU Adult/Gerontology Nurse

Practitioner, and 4). SDSU Women's Health Nurse Practitioner. The survey tool is a modified Depression Attitude Questionnaire, which has been used in various other research articles to assess the knowledge and attitudes of health care providers towards managing depression. Additional questions were added to assess

for comfort level of managing depression and demographic information. The questionnaire was distributed in person and electronically via Survey Monkey.

Conclusions Reached

Attitudes of APN students towards managing depression is positive, including feeling comfortable

assessing for depression and discussing depression related information with other health care professionals.

The study also showed significant correlation between APN student's increasing age and increased positive

attitudes towards depression. The study questions pertaining to knowledge were not found to be statistically

reliable and therefore were not included in the study findings.

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vi

First and foremost, I would like to thank my husband Bill for supporting me every

step of the way. You not only supported me through nursing school many years ago, you

encouraged me to continue my professional aspirations by returning to college yet once

again. You have provided me with endless of hours of verbal and emotional support,

advice, and cheering me on when I didn’t believe in myself. Thank you for taking such

good care of me, by making sure I got enough sleep, making sure I was eating, and even

making sure I took a day or two off. Plain and simple, I couldn’t have done it without

you.

I also would like to thank my two wonderful boys, Brandon and Ryan. I don’t

really think you knew what you were in for when Mom said she was going back to

school. But you have been supportive of me, and patient as you watched me spend

endless hours at the computer. I could not be more proud of the two of you, and so

grateful that I get to call myself Mom to both of you. I hope you will see this path I have

taken as a source of inspiration in your future aspirations.

I would like to thank my parents, who have given me hope and inspiration from

the very beginning. To my Dad, who started my interest in Nursing by taking me to

Mexico with him on a surgical mission trip some 23 years ago. To my Mom, who herself

choose the path of nursing and continues to show her compassion for others every day of

her life. You have supported me in this journey from the very beginning, never once

questioning my decision to return to school. You have also provided endless hours of

helping with kids, driving from place to place, and occasionally making a meal or two. I

am grateful to call you my parents, and grateful for the continued support of our family.

Finally, I would like to thank Dr. Carney, who graciously agreed to serve as my

committee chair. You have given me endless amounts of advice, and helped me to

maintain my sense humor through it all. To my other committee members, Dr. Boren, and

Dr. Romig, thank you for time, patience, and availability. Your advice and contribution to

this paper has been invaluable and very much appreciated. An extra thank you to Dr.

Axman, who also put in many hours with me to complete the complicated statistical

analysis part. You were very patient and kind.

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Preface ... i Acknowledgments... vi List of Tables ... ix Chapter 1. INTRODUCTION .………. 1

Background and Significance ... 2

Significance to Advance Practice Nursing………3

The Problem ... 4

Purpose of the Research ... 4

Research Question………. 4

Research Variables……… 4

Conceptual Model...5

2. LITERATURE REVIEW ... 6

Introduction ... 6

Theoretical Framework or Conceptual Model (if applicable)………. 11

Summary………...11

3. METHODOLOGY... 13

Introduction………..13

Research Question………13

Research Design………...13

Population and Sample……….14

Data Collection Process………14

Data Analysis………15 Bias………...15 Ethical Considerations………..16 Summary………...17 4. RESULTS………17 Introduction………..17

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Sample………..17

Instrument……….20

Data Collection and Preparation………...20

Challenges to Data Collection ……….25

Results by Research Question ……….25

Summary………..26

5. DISCUSSION……….27

Introduction………..27

Major Findings by Aim/Hypothesis/Question……….27

Limitations………...28

Generalizability………....28

Implications for Nursing Practice………28

Recommendations for Future Research………...29

Summary………..30

Appendix A. Depression Attitude Questionnaire………31

Appendix B. CSUSM IRB Approval Letter ... 34

Appendix C. CSUSM IRB Minor Modification Approval Letters………35

Appendix D. SDSU IRB Approval ………37

Appendix E. Email Study Invite Letter………..38

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ix

Tables

Page

1. Demographic Frequency Table…..………19

2. Reliability Analysis……….22

3. Factor Analysis for seven-item scale………..24

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CHAPTER ONE: INTRODUCTION

Depression is a common problem seen in primary care in the United States and is one of the most prevalent, disabling, and costly chronic health conditions. It affects more than 25 million Americans every year, regardless of age, race, or gender (NAMI, 2013). Unfortunately, primary care practitioners often do not recognize or diagnose depression in their practice. Depression at any age can have a unique

presentation and can have serious negative consequences for those whose depression remains untreated. Manifestations of major depression can hinder early detection, due to anxiety, somatic complaints, cognitive impairment, and concurrent medical and neurologic disorders. Depression can occur with other serious illnesses, such as heart disease, stroke, diabetes, cancer, and Parkinson’s disease. Thus, the gap between symptomatic depression and a diagnosis of depression disorder can be especially wide.

Depression increases the economic burden of the health care system, with depressed patients having twice the health care costs, twice the number of hospital days (Simon, Von Korff, & Barlow, 1995), and twice the number of medical appointments (Alexopoulos, 2001). In primary care populations, 75% of healthcare “over utilizers” were found to have clinically significant depressive symptoms (Katon, Von Korff, Lin, Bush, & Ormel, 1992). In addition to medical morbidity, and disability, depression increases the use of medical services, increases health care costs, and directly impacts the services and quality of care they receive.

The greatest limitation in depression treatment concerns access and delivery of treatment rather than treatment efficacy. According to a study by Brody et al. (1997), depressed primary care patients prefer to be treated by their own physicians, and over 80% of these patients reported to prefer receiving help for emotional distress by their primary care physicians, while only 5% desired referral to a mental health specialist (as cited by Alexopoulos, 2001). It is imperative that primary care providers incorporate screening for mental health and depression in every day practices.

Advanced Practice Nurses (APNs) frequently make comments regarding the need for more training to be able to deal effectively with patients with depression. However, according to Simon et al. (as cited by Alexopoulos, 2001) primary care provider’s frequently under diagnose these patients, identifying less than one half of depressed patients, causing a potential for decreased function and an increase in

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hospitalizations. Further casing under-diagnosis of depression include lack of training or inadequate knowledge, hesitancy to discuss sensitive issues, and non-effective communication skills. APN’s are increasingly becoming the first point of contact for patients, and therefore making it important to further investigate the overall knowledge and attitudes of graduate nurse practitioner students towards managing depression. It is also equally important that these providers feel competent in their knowledge of

depression, are comfortable in addressing the subject with their patients, and have the tools and resources needed to effectively treat and manage depression.

Background

Although the causes of depression remain unknown, new advances have increased the exploration of factors related to depression and its many manifestations. Studies have shown that there is a need for further education of APN students in diagnosing, treating, and managing depression in primary practice. An important reason for focusing on depression in primary care is the continued under diagnosis of depression in the medical setting (Alexopoulos, 2001). Even when depression is diagnosed, and patients are referred to a mental health specialist, as many as half do not contact the specialist (Alexopoulos, 2001).

Despite efforts to improve diagnosis and treatment, many cases remain under-diagnosed and incorrectly treated (Alexopoulos, 2001). Treatment for depression is critical and its detection in the primary care setting is a pre-requisite of effective management. The fact that depressive disorders present with irregular symptoms, the resistance of people to acknowledge and report their symptoms, and the increased pressure of providers to spend less time with their patients, leads to a low recognition rate. Gaps between what we know and what we need to know in the diagnosis and management of depression still exist, especially how depression interacts with chronic illnesses, how to measure the quality of care for depressed patients, and how to provide care that provides good outcomes for all people, regardless of the cost. Developing more effective strategies to translate knowledge into improved care is an important area for future research. APN education and training initiatives in primary care will be vitally important to improving the treatment and knowledge of depression management.

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Significance to Advanced Practice Nursing

As more nurses continue to seek a higher education, the APN has an important role to play in meeting the needs of depressed patients. Primary care providers are often the first contact that patients will make when symptoms of depression become too extreme. Physical problems often compete with

depression for attention, possibly decreasing the odds that the patient will receive appropriate treatment. In addition to primary care provider’s lack of specific training and being uncomfortable assessing for depression, they also lack educational support and difficulty accessing mental health specialists (McCabe, Mellor, Davison, Hallford, & Goldhammer, 2012). Thus, educational strategies aimed at increasing APN’s comfort and skill in depression assessment and care management are likely to be successful (Mayall, Oathamshaw, Lovell, & Pusey, 2004).

The APN education is known for its holistic approach and understanding of mind-body

interactions, but unfortunately few APNs have been exposed to specialized knowledge about depression in their graduate education (Delaney & Barrere, 2012). It is important to note that patients may not talk about sadness or anxiety, but rather, about the physical manifestations of an upset stomach, backache, headache, sleepless nights, fatigue, or memory loss. APNs practice in a variety of settings and need to be aware of these symptoms and co-occurrence of depression, which can lead to further medical morbidity and disability. With a shortage of mental health professionals, it often falls to primary care providers to treat certain psychiatric conditions. Therefore, non-psychiatric nurse practitioners must be able to recognize common symptoms of psychiatric disorders, know how to treat less complex mental illnesses, and know when to refer to a psychiatric specialist, such as a psychiatric nurse practitioner. All APN’s have the ability to reduce the negative effects of depression through early recognition, intervention, and referral of patients with depression.

Nurses are at the front-line of health care professionals and are in a great position to detect depressive symptoms and initiate pathways to care. However, previous research (McCabe, Mellor, Davison, Hallford, & Goldhammer, 2012) suggests that nurses' confidence and skills related to diagnosing and treating depression are low, and there appears to be a number of barriers that may keep nurses' from being involved. Issues that have been identified include the need for further training to recognize the signs

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and symptoms of depression, the ability to discuss depression with patients and their family members, and difficulty differentiating depressive symptoms from grief or other physical ailments.

Problem Statement

Advanced Practice Nursing students do not have appropriate knowledge and attitudes to manage depression. There have been no previous studies that have looked specifically at the knowledge and attitudes of nurse practitioner student’s towards depression, prior to graduation. Current research focuses primarily on the attitudes around licensed NP’s and physicians, and their comfort level with managing depression.

Purpose of Research

The purpose of this research is to assess the current knowledge and attitudes towards managing depression among Advanced Practice Nursing students.

Research Question

What are the current knowledge and attitudes of Advanced Practice Nursing students towards managing depression?

Research Variables

Graduate Nurse Practitioner Student/Advanced Practice Nursing Student. This is defined as

an individual who already holds a current RN license and is currently enrolled in a graduate level/masters level nurse practitioner program.

Depression Knowledge. As defined by the Merriam Webster dictionary (2013), knowledge is

considered information, understanding, or a skill that a person gets from experience or education. It is an awareness of something, or the state of being aware of something. According to the Nursing Outcomes Classification (2012), depression knowledge is a nursing outcome defined as the extent of understanding conveyed about depression and interrelationships among causes, effects, and treatments.

Depression attitudes. Defined by the Merriam Webster Dictionary (2013), attitudes are the way

an individual feels about someone or something. It is a way of feeling or thinking that affects a person’s behavior. Depression attitudes are defined as the way an individual views and perceives the ability to care for and treat patients with depression.

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Conceptual Model

Bandura’s theory of Self Efficacy will be applied when discussing the nursing concept of knowledge and attitudes in depression management. “Self-efficacy is defined as an individual’s judgment of his or her capabilities to organize and execute course of action. At the core of self-efficacy theory is the assumption that people can exercise influence over what they do” (Peterson & Bredow, 2013, p.82). The concept of self-efficacy was developed by Bandura in the mid 1970’s and is based on social cognition theory. It is the belief that one has the power to produce that effect by completing a given task or activity related to that competency. This theory can also be used as a foundation for determining additional research on changing self-efficacy perceptions of APN’s when addressing depressive symptoms in their patients.

“Self-efficacy expectations are judgments about personal ability to accomplish a given task and outcome expectations are judgments about what will happen if a given task is successfully accomplished” (Peterson & Bredow, 2013, p. 83). If the APN believes that he or she has the ability to succeed in specific situations, then one’s sense of self-efficacy will play a major role in how one approaches goals, tasks, and challenges. If the APN has confidence in their ability to diagnosis and treat depression, then the patient will also benefit from treatment. According to Bandura's theory, people with high self-efficacy, or those who believe they can perform well, are more likely to view difficult tasks as something to be mastered rather than something to be avoided. It should is the expectation of APNs that one can master a situation, such as increased knowledge and attitudes in depression management, and produce a positive outcome.

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CHAPTER TWO: LITERATURE REVIEW Introduction

The databases reviewed for this literature review included CINAHL, PubMed, Psychinfo, and Google Scholar. Literature search terms included depression, depression management, depression knowledge, nurse practitioners, APN, primary care providers, general practitioners, barriers to depression treatment, self-efficacy, and the depression attitude questionnaire. The search was limited to English, peer-reviewed articles published after 1990, as there is very limited research prior to that date specifically focusing on nurse practitioners. Therefore, some of the articles reviewed do not focus solely on the role of the nurse practitioner, but on the role of general practitioner or primary care provider. The literature further indicates that primary care providers do not have the appropriate education to manage depression.

Botega, Mann, Blizard, & Wilkinson (1992) developed the Depression Attitude Questionnaire (DAQ) to assess general practitioners’ attitudes toward depression in primary practice. The instrument was validated at that time and had good reliability (as cited by Burman, McCabe, and Pepper, 2005). Botega and Silveira (1996) went on to conduct a cross sectional study designed to assess the attitudes of general practitioners working in primary health care in Brazil, also utilizing the DAQ (Botega, Mann, Blizard, & Wilkinson, 1992). Visual analogue scales were used and responses were measured in millimeters and divided into five categories: strongly disagree (0-20 mm), disagree (21-40 mm), “neutral” (41-60 mm), agree (61-80 mm), and strongly agree (81-100 mm). Their results indicated the need for additional educational programs that aim at increasing the diagnostic and management skills of general health practitioners.

Kerr, Blizard, and & Mann (1995) sampled 74 practitioners and 65 psychiatrist in Wales, England, by a mailed questionnaire. Attitudes towards depression between the two disciplines were assessed by the DAQ (Botega, Mann, Blizard, & Wilkinson, 1992). General practitioners had a significantly different attitude than psychiatrist when dealing with depression and the identification of depression. Their study indicated that the DAQ (Botega, Mann, Blizard, & Wilkinson, 1992) might prove to be a useful tool in providing educational initiatives to improve primary care detection and management in depression. The

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authors also stated that it might be useful to use this questionnaire to compare general practitioner attitudes with those of psychiatric nurses.

Another early study by Mann et al. (1998) researched the impact of “practice nurses” in England, on assisting primary care doctors with depressed patients. They evaluated two interventions of practice nurses that worked jointly with general practitioners (GP) in the treatment of depressed patients. 56 GPs, 21 practice nurses, and 577 patients participated. The interventions included standard psychiatric assessment by the practice nurse, providing information of the patient to the GP (Group 1) and then a follow up intervention at four months by the practice nurse (Group 2). There was also a control group that did not receive treatment. The DAQ (Botega, Mann, Blizard, & Wilkinson, 1992) was filled out by both the GP and the practice nurse at the beginning and end of study. The effect of trial participation was assessed by comparing scores on individual items. Although they found no additional benefit for patients who received a nurse intervention at four months, they did find that additional training for nurses in assessing patients and providing follow-up care was associated with increased outcomes. There was also a shift in attitudes and management of nurses that is beneficial for the improvement of depression. This was one of the largest evaluations of the treatment of depression in general practice to date, and although the focus was on “practice nurses” rather than APN’s, it still implies the benefit of a nurse approach and the need for additional education and training regarding depression management.

In 2004, Richards, Ryan, McCabe, Groom, & Hickie aimed to investigate the barriers to effective management of depression in general practice. This study involved a direct survey of urban and rural GPs in Australia. The aim of this study was to investigate the impact of GP’s previous mental health training on their attitudes towards depression, their confidence in depression management, and on the obstacles they identified to effectively manage this condition. A total of 420 GPs (69%) completed and returned the surveys. The questionnaire concentrated on current clinical practice, perceived barriers to care for

depressed patients, and the GPs self-efficacy for assessing and treating depressed patients. It also consisted of two scales that had been used in previous research, designed to assess doctors’ attitudes towards

depression and depressed patients. One of these scales was the DAQ (Botega, Mann, Blizard, & Wilkinson, 1992), further validating its reliability. Their results showed that GPs who had taken continued education

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courses on mental health and had recent training, chose to use non-pharmacological treatments rather than prescribing medication for depression. Those without recent mental health training stated a lack of knowledge about depression as a barrier to treatment. Overall, GPs with mental health training were more positive in their attitudes toward depression and their treatment of these patients. Their study concluded that GPs who actively participated in mental health training had more positive attitudes towards depressed patients, and had more confidence in their abilities to diagnose and manage this type of patient. This study indicates that additional mental health training for American NP’s would not only benefit the patient, but would also provide additional confidence to the provider who is diagnosing and managing depression.

Another study that focused on the role of nurse practitioners was done by Burman, McCabe, & Pepper (2005). The aim of their study was to investigate the barriers to treatment and screening practices of primary care APNs related to depression and anxiety, in the state Wyoming. Every primary care nurse practitioner in Wyoming received a questionnaire asking them about attitudes towards depression and anxiety, screening and treatment practices, and any treatment barriers. One hundred and eight APNs met criteria and were mailed questionnaires. Fifty-two were returned, for a return rate of 55.3%. Additionally, the DAQ (Botega, Mann, Blizard, & Wilkinson, 1992) was administered to determine providers’ attitudes toward depression and mental illness. This study was based upon self-reports of primary care APN’s, who documented their depression screening and treatment practices. Their findings indicated “the need for further research exploring actual practices and outcomes and to explore the impact of educational interventions on APN screening and treatment practices” (p.377). Given the amount of patients seen by PCPs that have depression and anxiety, it was confirmed that the education of APNs in primary care is not adequate.

In 2011, Kravitz et al. attempted to identify attitudinal and interpersonal barriers to depression care and evaluate the primary care paradigm to depression. They organized focus groups of people who had experiences with depression, and asked their opinion about individual, interpersonal, and organizational barriers to seeking care. Some individuals felt that PCPs lacked the knowledge and skills to adequately care for depression. Others stated that the problem was a perceived lack of depression specific expertise, or a lack between formal and practical knowledge. The overall problem discovered was not just skills and

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capabilities, but also a matter of interest and empathy. Their conclusion was that patients with depression may be discouraged from seeking care due to or relational barriers including PCPs’ perception of mental health. They further concluded that PCPs should continue to develop their depression management skills and increase their efforts to educate the public that primary care is a safe and supportive avenue for treatment of common mental health problems. Implications for future practice should look at the patients’ reservations about PCPs’ competence, openness, or trustworthiness, and how this may inhibit

communication of critical clinical information, recognition, and treatment of depression in primary care. According to Delaney & Barrere (2012), no studies have focused on graduate students' knowledge needs related to depression management. The aim of this study was to examine the knowledge, attitudes, and self-efﬁcacy of advanced practice nursing students toward depression in older adults. Although their study focused on the older population, their study also revealed many details that pertain to the current practice of all NPs, regardless of the population they treat. A total of 119 APN students enrolled in graduate nursing programs from both a public and private university, completed an online survey, modified from the DAQ (Botega, Mann, Blizard, & Wilkinson, 1992) and the Late Life Depression Quiz (Pratt, Wilson, Benthin, & Schmall, 1992). A cross-sectional, descriptive design was used to study a convenience sample of advanced practice nursing students from two universities in Connecticut. First and second year students who were enrolled in primary care, acute care, and family nurse practitioner tracts were included. The aim of this study was to examine the knowledge, attitudes, and self-efﬁcacy of advanced practice nursing students toward depression in older adults. It was the first research study that focused on the confidence and ability of APN students to diagnosis and treat depression in older adults. Their findings suggest that advance practice nursing students may not have enough knowledge in evidence-based screening and interventions to manage depression. However, it is not just the older population that is in need of additional depression management, it is the entire adult population. Delaney & Barrere (2012) believe that depression requires a more holistic approach for optimal outcomes, focusing on the body, mind, and spirit. Their current study aimed to close the gap in the literature by examining graduate nurses' knowledge level, self-efficacy, attitudes, and educational needs for holistic depression management in older

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adults. This study also proved there is a need for further research in regards to depression management in the general adult population.

Although some reports suggest that Primary Care Providers (PCPs) prefer having their behavioral health associates provide mental health services in primary care, others believe this view is not necessarily true. Beacham, Herbst, Streitweiser, Scheu, & Siebe (2012) state that when PCP’s have a negative attitude towards mental health, caused by a lack of understanding of psychological structure, difficulty referring patients to mental health services, and a continuing tendency for patients and medical providers to stigmatize mental health services. Their study looked at whether the attitudes of PCPs toward behavioral health services would differ depending on whether a PCP had access to onsite mental health services. Their study divided providers into two groups, a Federally Qualified Health Center (FQHC) and a

Community Based Center. This study was one of the few that actually included Nurse Practitioners, and the FQHC sample was compromised of 16 physicians and 15 nurse practitioners at five clinics in an urban and surrounding area of a metropolitan city. Things that may affect the attitudes of PCP’s regarding the

treatment of mental health include whether there is less access to behavioral health professionals or whether these professionals are not very helpful. PCP’s may therefore not actively seek to identify mental health needs of patients if they cannot provide the proper support or referral. In addition, there is a need to improve efforts in education of PCP’s about mental health services available, providing the necessary resources to facilitate access and follow up.

In 2013, Groh published a study reflecting implication for Nurse Practitioners caring for women in rural areas. The significance of this study is that more and more Nurse Practitioners are choosing to practice outside of urban areas, and focusing on less populated areas. Geller states (as cited by Groh, 2013) that rural men and women are more likely to use their primary care provider for their mental health needs. One of the reasons PCPs fail to detect mental health problems is due to insufficient mental health training, and thus an inability to recognize mental health disorders, such as depression (Groh, 2013). In addition, “it is reasonable to assume that depression in rural women may go unrecognized by both the women and her primary care provider and thus, untreated” (Groh, 2013, p. 84). Groh’s study collected data from 140 women who lived in a rural community in the Midwest. The study used a descriptive, non-experimental

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survey design, where each participant was asked to fill out a standardized screening tool for depression. The purpose of this study was to determine whether rural women would self-report as depressed when asked, and to explore congruence between self-report of depression and the Center for Epidemiologic Studies-Depression Scale (CES-D). While the study showed that the majority of women were congruent with self-reporting of depression and their CES- D results, there were still 25% of women that were not congruent. More often than not, these women also reported chronic health conditions, such as arthritis, hypertension, headaches, backaches, female problems, and chronic pain. This information can ultimately guide patient education and the clinical practice of NP’s who serve in rural communities. In addition, the study results are also important to the practice of APN’s, as the workforce data shows that 10% of family NP’s are choosing to work in rural areas (Groh, 2013). In addition, according the U.S. Department of Health and Human Services , Health Resources and Services Administration (2010), 64.5% of NP’s are working in ambulatory or primary care , where it is likely to assume that the NP’s will the primary care providers most likely to assess and treat depression in rural men and women. Groh’s study has offered new information to the lives of a specific population in the rural communities, and the value that NP’s can bring to improve the mental health of these women and communities.

Conceptual Model

As stated earlier Bandura’s Theory of Self Efficacy can be applied to advanced practice nursing concepts of depression management. Self-efficacy is defined as a person’s personal judgment regarding their ability to organize and fulfill a specific task. At the core of self-efficacy theory is the assumption that people have influence over what they do (Peterson & Bredow, 2013). It is the belief that one has the power to produce the effect they want, by completing a task or activity related to that competency. Thus, by increasing depression knowledge of nurse practitioners and providing additional education, attitudes regarding the management of depression will improve.

Summary/Conclusion

Between 2014-2014, there have been an increasing number of research studies devoted to interventions and treatment, seeking to improve the care of the depressed patients. However, despite this research, depression continues to be undertreated. Current literature states that primary care providers do

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not have the appropriate education to manage depression. In addition, several authors have noted that APN’s are in an optimal position to address the integral link among depression, chronic disease, and overall well-being of adults. These studies continue to emphasize the need to improve APN’s abilities to accurately assess and manage depression, as well as provide additional research on the educational preparation of nurse practitioners. APN’s practice in a variety of health settings, and therefore are in a strategic position to assess for depressives symptoms, as well as collaborate with the patient/family and other health care professionals

What appears to be the most important point in the literature is that health care providers continue to state they do not have the appropriate education to accurately manage and treat patients with depression. To date, there have been few studies that have focused on the graduate nursing students’ current knowledge and attitudes related to depression management. This thesis is aiming to close the gap in literature regarding the current clinical paradigm and depression knowledge and attitudes of APN students.

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CHAPTER THREE: METHODOLOGY Introduction

Prior research looking at nurse practitioner’s knowledge and attitudes about depression

management is very limited. It is even further limited when considering advanced practice nursing students. Previous studies assessing the knowledge and attitudes of primary care providers towards depression management (Botega et al, 1992; Botega & Silveira, 1996;Delaney, & Barrere, 2012; Haddad, Walters, & Tylee, 2007;Norton, Pommie, Cogneau, Haddad, Ritchie, & Mann, 2011) have routinely used the

Depression Attitude Questionnaire (DAQ) developed by Botega et al. (1992). The DAQ instrument was also chosen for use in this study. Although it has shown limited reliability in previous studies (Haddad, Walters, & Tylee, 2007; Norton, Pommie, Cogneau, Haddad, Ritchie, & Mann, 2011), it has shown validity by having questions developed from content experts, and by being used in other research studies. Many researchers have chosen to adapt the instrument so that it best applies to their current population. For the purposes of this thesis, the DAQ was also modified to more appropriately serve the population of advanced practice nursing students.

Research Question

There have been no previous studies assessing the knowledge and attitudes of advance practice nursing students towards depression. Therefore, the research questions is “What are the current Knowledge and Attitudes of Advanced Practice Nursing StudentsTowards Managing Depression?”

Research Design

A cross-sectional, descriptive design was used to study a convenience sample of advanced practice nurse practitioner students from CSUSM and SDSU Schools of Nursing. The rationale for this type of design is that data was collected at a single point in time. An online survey and paper/pencil approach was used to collect data from graduate students enrolled in Nurse Practitioner (NP) programs about their knowledge and attitudes towards managing depression. Threats to internal validity included the reliability of the instrument, whether all questions applied to nurse practitioner students, and/or whether the

participant understood the question appropriately. The limitation of this design was primarily the small sample size. Sampling was limited to current students enrolled in graduate nurse practitioner programs at

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CSUSM and SDSU colleges of nursing. It may also not accurately reflect the knowledge and attitudes of all nurse practitioners students. Lastly, participants submitted the questionnaires voluntarily, thus not all students that were eligible to participate chose to do so.

Sampling Plan

A non-random convenience sample of advanced practice nursing students was recruited from CSUSM and SDSU Schools of Nursing. Students were eligible to participate if they were 1) a registered nurse currently enrolled in the FNP program at CSUSM, or either the Adult/Gerontology or Women’s Health NP programs at SDSU, and 2) willing to participate. Limitations of the proposed sample’s generalizability was that the participant must be enrolled in one of the NP programs at the two chosen universities, and thus participants may not be a true representative of entire population of NP students.

Data Collection Process

IRB approval was obtained prior to the start of the data collection process at each university. The principal investigator then visited cohorts during designated class time via instructor permission. The study was explained and student participation was requested. An information sheet was supplied to each student explaining the study, length of time estimated to complete the study, and information regarding

confidentiality. Time was allowed for questions and answers during the orientation session. NP students were also contacted and invited to participate via e-mail through the schools of nursing mailing lists at both universities. The study purpose, process, and time frame for questionnaire completion was explained. Participants that were interested then clicked on a link to the electronic survey. The survey was accompanied by an information sheet explaining that the survey was anonymous and participation was voluntary. Consent of the advanced practice-nursing student was assumed by the return of a completed survey. No personal identification information was collected. Data was collected at one point in time, at the convenience of the participant. Demographic information was also collected and included: age, gender, years of practice as an RN, current specialty, ethnicity, and number of clinical hours completed.

Data collection was done by utilizing the Depression Attitude Questionnaire (DAQ)

(

Botega, Mann, Blizard, & Wilkinson, 1992). The DAQ is a self-report 20-item survey investigating the knowledge

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and attitudes of depression by the provider. It was modified from its original version and included questions that are more appropriate to nurse practitioners and included questions inquiring about both knowledge and attitudes of depression management. The DAQ was measured on a 5-point Likert Scale ranging from “strongly disagree to strongly agree.” Although no internal consistency has been noted to confirm reliability of the instrument, modified versions have been used in many studies. One such study (Norton, Pommie, Cogneau, Haddad, Ritchie, & Mann, 2011) performed a factor analysis on each individual question and found each component varied from 0.4 to 0.65 with an overall internal consistency of 0.47 (Cronbach’s alpha). Thus, a post hoc analysis was performed to further confirm reliability at the end of this study. The validity of the instrument has been confirmed by content experts who developed the questions and has been used in other research studies.

Data Analysis

IBM SPSS 20 software was used to analyze the data. Descriptive statistics were used to determine frequency of responses. There were no correct responses. Percentages of how students responded was reported in a frequency distribution table. Demographic information was collected to describe sample population, and answer study question. The 5-point Likert Scale was coded using ordinal measurements as follows: strongly agree (4), agree (3), disagree (2) and strongly Disagree (1). Demographic information collected was age (ratio), gender (nominal), specialty (nominal), clinical hours (scale), and years of practice (ordinal).

Biases or limitations

Limitations to this study are a small sampling population of current NP students enrolled at CSUSM and SDSU. It is also a convenience sample, thus participants self-selected to participate. The sampling population may also not be a true representation of the target population. Instrumentation issues may result in personal bias and participant’s ability to self-assess their skills. This issue was attempted to be controlled by reminding participants that no personal information was collected and all responses were anonymous.

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Ethical considerations

The CSUSM and SDSU Institutional Review Board (IRB) approval was obtained, and no one under the age of 18 was included in the research. At this time, no participants were considered to be part of an at-risk population. No incentives were offered for participation. Consent for participation was assumed by each participant clicking on the appropriate link to the survey, or turning in their paper/pencil

questionnaire. Confidentiality was protected for participants by not collecting any identifiable information via Survey Monkey or paper/pencil questionnaire. Approval letters can be found in Appendix B,C, and D.

Summary

Data collection proved to be more challenging than anticipated, due to delayed response from SDSU administrators and obtaining access to their students. Recruitment was based upon an email invitation, as well as in person. Those participants who chose to take the questionnaire online, did so on their own time and at their convenience. This possibly led to a lower percentage of response rates. Data collection was originally limited to the student having completed 135 clinical hours. However, due to the low response rate and delay of having access to SDSU students, criteria for minimum number of clinical hours was eliminated. Lastly, as the DAQ was adapted to be more applicable to the APN student, there still may have been confusion or lack of comprehension regarding the questions that were asked. In the end, the ultimate aim of this study was to have a better understanding of how nurse practitioner students view the management of depressed patients, and whether they have the adequate knowledge and attitudes to treat this high-risk population.

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CHAPTER FOUR: RESULTS Introduction

Chapter Four provides the results for the research question “What are the Knowledge and Attitudes of Advanced Practice Nursing Students Towards Depression?” The data was examined using IBM SPSS Statistics 20 software (2011) for frequency, mean, median, mode, and distribution if applicable. Following frequency distribution analysis, data were analyzed for correlations using Pearson’s correlation. A factor analysis was also performed to confirm reliability of each question. Reliability was confirmed for seven of the twenty-six questions, with an accuracy rate of between 68-72%.

Sample

The sampling frame consisted of Registered Nurses enrolled in the Family Nurse Practitioner students at CSUSM, and the Adult/Gerontology Nurse Practitioner Students or Women’s Health Nurse Practitioner students at San Diego State University.

The original criteria included that all participants must have completed at least 135 clinical hours. However, due to difficulty of gaining access to the SDSU students, enrollment was opened to all students enrolled in one of the stated programs, regardless of number of clinical hours completed. Additionally, Women’s Health NP students were included due to the low number of participants, and three Psychiatric NP Students from CSUSM were included due to inadvertently being emailed the questionnaire. A minor modification form was submitted to CSUSM IRB for all of these changes, and was approved.

The sample was one of convenience. All variables were examined for normality using mean, median, and mode. Study participants were described using frequency distribution. All of the students must have been enrolled in one of three types of APN programs, with a final total of fifty-two participants. The three types of students responding were CSUSM FNP (n= 42: 80%), SDSU Adult/Gerontology NP (n= 3: 5.8%), and SDSU Women’s Health NP (n= 4: 7.7%). There were three students that identified their current program as mental health (5.8%). The student’s gender were reported as female (n=49: 94.2%) and male (n=3: 5.8%) The participants age (Table 1) ranged from 26-58 years age, with a mean age of 36 years old and a median of 35 years old. The number of years the study participant had been practicing as a registered

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nurse (Table 2) ranged from 2-30 years, with a mean of 8.4 years of practice, and a median of 7 years of practice. The majority of participants identified their ethnicity as Caucasian, which included half of the sample size (n=26: 50%). The most common specialty (Table 3) cited was Acute care/Intensive Care Unit (17.3%), followed by Emergency Department (13.5%), and medical-surgical nursing (9.6%).

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Table 1 Demographics Total (n = 52) No. % Age 25-30 31-35 36-40 41-45 46-50 51-55 55+ Years of Practice 2-5 6-10 11-15 16-20 21-25 26-30 Nursing Specialty Acute Care/ICU Cardiac ER

Labor & Delivery Med-Surg Telemetry Trauma Urgent Care Pediatrics Mental Health Other 18 11 6 9 5 1 1 23 13 8 2 2 1 9 3 7 4 5 4 3 2 2 3 52 34.6 21.1 11.5 17.2 9.6 1.9 1.9 44.3 30.7 15,3 3.8 3.8 1.9 17.3 3.8 13.5 7.7 9.6 7.7 5.8 3.8 3.8 7.7 9.2

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Instrument

The instrument used was a modified version of the Depression Attitude Questionnaire (DAQ), which was developed by Botega, Mann, Blizard & Wilkinson (1992). The DAQ is a self-report 20-item survey investigating the knowledge and attitudes of depression by the provider. The tool was first used to measure general practitioners attitudes towards depression in general practice. Participants of the original DAQ were asked to indicate a point on a visual analog scale, using a 100 mm scale, ranging from “strongly disagree” at one end to “strongly agree” at the other. A factor analysis by Botega et al (1992) reported that 17 of the 20 statements resolved into three components. These components were 1) attitudes toward treatment, 2) depression knowledge, and 3) professional ease.

For this study, the DAQ was modified from its original version to include questions that were more appropriate to nurse practitioners and also included six additional questions inquiring both the knowledge and attitudes of depression management. Each question was placed on a Likert scale, including Strongly Disagree (1), Disagree (2), Agree (3), and Strongly Agree (4). The survey was divided into three subscales, including depression knowledge, depression attitudes, and professional ease.

No internal consistency has previously been noted to confirm reliability of this instrument, although modified versions have been used in many studies. Hadded, Walters, & Tylee (2007) performed a factor analysis with aCronbach's α between 0.59 and 0.64. Norton, Pommie, Cogneau, Haddad, Ritchie, & Mann (2011) also performed a factor analysis on each individual question and found each component varied from 0.4 to 0.65 with an overall internal consistency of 0.47 (Cronbach’s alpha). Therefore, a post-hoc analysis was done in this study, showing only seven of the twenty-six questions were found to be reliable, giving a total Cronbach’s alpha of 0.75.

Data Collection and Preparation

After obtaining informed consent, the modified Depression Attitude Questionnaire (DAQ) was administered. Students were initially invited to participate via a school wide email .The participants then self-selected to be included in the study by completing an online questionnaire via survey monkey. Due to unanticipated challenges of gaining access to SDSU students, additional CSUSM FMP students were also

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approached in person, during class time and invited to participate via paper/pencil. Data was then entered manually into Survey Monkey. After three weeks of data collection, the survey was closed to new input. The DAQ had been given a modified coding scheme a priori. All nominal and ordinal data were converted to numerical values for analysis in SPSS. Data from the coded questionnaires was then entered into SPSS 20 (IBM, 2011), double- checked for accuracy and data analysis performed. All cases were examined for data entry errors and descriptive statistics were reviewed for all variables. All variables were examined for distribution.

The DAQ and its subscales as modified for this study were evaluated for reliability. Of the three subscales only the “Attitudes” subscale demonstrated acceptable reliability, with a Cronbach’s Alpha of 0.75. Additionally, one question from the “Professional Ease” subscale was retained because it explained an additional sixteen percent of variability in Exploratory Factor Analysis described below. No items from the “Knowledge” subscale were retained. Table 4 illustrates the reliability analysis for the seven-items used to answer the research question for this study.

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Table 2

Reliability Analysis for DAQM (N = 47) 2a

Item Item – total

correlation

Alpha if deleted

item

Q4. I feel comfortable dealing with depressed patients’ needs Q.8. It is rewarding to spend time looking after depressed patients

Q12. Antidepressant therapy in general practice usually produces a satisfactory result

Q.18. Nurse practitioners have an important role in the identification and management of depression

Q.21. I am comfortable assessing for depression

Q.22. I am comfortable planning evidence-based interventions for an adult

Q.23. I am comfortable discussing depression-related information with other healthcare providers

.59 .47 .15 .31 .58 .59 .57 .69 .72 .78 .75 .70 .69 .70

Note. Cronbach’s Alpha for 7-item DAQM2 = .75 with a Mean of 20.49 and a Standard deviation of

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Factor Analysis. The seven-item instrument was evaluated for a number of components or subscales using Principal Component Analysis with Varimax rotation. The primary purpose for using Principle Components Analysis with Varimax rotation was to identify the distinct factors underlying the modified version of the DAQ in this sample of NP students. Factors that accounted for at least five percent of the variance and had an Eigen value of at least one (1) were retained. The initial seven-value solution showed that the first factor explained 42 % of the variance and the second factor 16% of the variance. The two-factor solution explained 58% of the variance. A three-factor solution was not obtained. The seven-item (2 component) scale was used to answer the research question. Table 5 presents the Factor Analysis for the seven-item scale. Table 6 presents descriptive statistics for the DAQ two factor solution.

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Table 3

Rotated Factor Matrix for the 7-Item DAQM2a (N = 47)

Factor Descriptor

Q.4. I feel comfortable dealing with depressed patients’ needs Q.8. It is rewarding to spend time looking after depressed patients

Q12. Antidepressant therapy in general practice usually produces a satisfactory result Q.18. Nurse practitioners have an important role in the identification and management of depression

Q.21. I am comfortable assessing for depression

Q.22. I am comfortable planning evidence-based interventions for an adult

Q.23. I am comfortable discussing depression-related information with other healthcare providers b 1 .72 .62 .15 .50 .79 .75 .75 2c .30 .06 .92 -.41 -.15 .04 .05 2d h .60 .38 .86 .42 .64 .56 .56

Note. N = 47. Extraction method: Principal component analysis. Rotation method: Varimax rotation. All retained items with initial Eigen values 1 or greater. Rotation converged in 3 iterations. Cronbach’s alpha reported for primary factor loadings (bold type) rounded to second decimal place. a DAQM2 = DAQ + DAQM items as modified for this study. bFactor 1 = Attitudes. cFactor 2 = Professional Ease. dh2 = extraction (final) commonalities (row sum of squared loadings) rounded to two decimal places.

Table 4

Descriptive Statistics for the DAQM Two-Factor Solution (N=47) 2a

Factor No. of Items M (SD) Skewness Kurtosis Cronbach’s a

1. Attitude 6 17.79 (2.57) .62 .07 .78 2. Professional Ease 1 2.7 (.51) -.40 -.72 b

Note. DAQM = DAQ + DAQM items as modified for this study. Unable to compute Cronbach’s alpha for one-item.

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Challenges to Data Collection

Data was first attempted to be collected via electronic survey through Survey Monkey. This email was distributed through the school wide email system to all of FNP students at CSUSM who may have completed at least 135 clinical hours. In the interim, there was difficulty obtaining access to SDSU APN students due to administration being too busy to distribute survey. It was therefore decided to change inclusion criteria to include any APN student enrolled in any one the of the eligible NP programs, with no minimum clinical hours. At that time, the study coordinator was given permission to attend several classes with FNP students and manually distribute survey. It was then manually entered into the data base via Survey Monkey. IRB minor modification forms were submitted for all changes and approved. After several weeks, SDSU faculty were finally able to approve the distribution of the survey, and an additional seven students responded.

Results by Research Statement

The research questions was “What are the Current Knowledge and Attitudes of APN Students Towards Managing Depression?” To answer the question, the twenty-seven questions were divided into three sub-categories, 1) knowledge, 2) attitudes, and 3). professional ease, based upon the original DAQ. Only two of the sub-categories were shown to have questions with proven reliability, attitudes and professional ease. No knowledge questions showed enough reliability to be included in the study.

A bivariate correlation showed no statistical difference between attitudes and professional ease, based upon current specialty, gender, race, program, or number of clinical hours. There was however, a statistical difference between age and attitudes of depression. Seven factors were derived from the modified DAQ accounting for 68-72% of the variance. The significance demonstrated that as participants become older, their attitudes towards depression improve. Three questions (Table 6) showed a positive correlation between age and attitude towards depression. The strength of the correlation was moderate.

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Table 4

Correlation between age and attitudes towards depression

Age Ques_4_DA Q_9 Ques_21_DAQ _21 Ques_22_DAQ _22

Age Pearson Correlation Sig (2 tailed) N 1 52 .289* .038 52 .314* .026 50 .339* .018 48 *correlation is significant at the 0.05 level (2 tailed).

The three questions that were positively correlated were question 4) I feel comfortable dealing with depressed patient’s needs, question 21) I am comfortable assessing for depression, and question 22)I am comfortable in planning evidence-based interventions for an adult.

Summary

The DAQ instrument proved to be an unreliable instrument to measure the knowledge of APN student’s towards depression. However, it was determined that the overall general attitudes of APN students towards depression is favorable, and APN students are comfortable assessing for depression. This study also demonstrated that as an individual becomes older, they have an increasing positive attitude towards depressed patients. It was further determined that APN students feel comfortable discussing depression related information with other health care providers.

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CHAPTER FIVE: DISCUSSION Introduction

Only seven questions out of twenty-seven on the modified DAQ were reliable, and thus this study was only able to measure attitudes and professional ease. Factors such as gender, school program, current specialty, clinical hours, and years of practice had no statistically significant relationship to knowledge and attitudes towards depression.

Major Findings by Question

The research question was “What are the knowledge and attitudes of Advanced Practice Nursing Students towards depression?” Consistent with other studies (Burman, McCabe, & Pepper, 2005), APN student attitudes were generally positive regarding depression management. Burman, McCabe, & Pepper (2005) showed that APNs generally feel positive about treating depressed patients. The data also indicated that APN students are quite comfortable assessing for depression, and feel comfortable discussing

depression with other professionals. The data further indicated that as a participant becomes older, their comfort level and attitudes increase towards depression. Another study (Delaney & Barrere, 2012), also supported the statement that APN students felt comfortable discussing depression related information with other healthcare providers.

Although this study was not able to confirm APN student knowledge of depression, previous research states that while APNs in practice have a positive attitude towards depression, there is still a documented need for additional mental health training (Burman, McCabe, & Pepper, 2005; Delaney & Barrere, 2012; Groh, 2013). Overall, APN students in this study, as well as practicing APNs are interested in additional education regarding depression management.

Returning to the theoretical framework of Bandura’s concept of self-efficacy, at the core is the assumption that people can exercise influence over what they do. An example of utilizing this theory is the first Introductory Clinical Course in Psychiatric Management (Weber & Snow, 2006) at the University of Texas. Since 1999, all NP students at the University of Texas at Arlington, regardless of specialty, have been required to take this course. They have found most students feel more comfortable assessing for depression after taking this course. They have also had faculty requesting to take the course because their

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graduate education did not provide them with the appropriate knowledge needed for depression

management. A course such as this provides that self-efficacy training and education an APN student needs to improve their knowledge and increase their attitudes towards depression. It has often been used in nursing literature to discuss knowledge, motivation, and behavior related to health care practices. This theory can be utilized when evaluated APNs self-perceived knowledge regarding depression. By providing additional education and giving additional resources, APNs attitudes and knowledge towards depression may change or improve.

Limitations

Data for this study was collected from two different universities in California and therefore caution should be exercised when generalizing its findings to other universities and APN students. A more comprehensive study involving other public and private universities could yield data that are more conclusive. The instrument for this study was a self-administered questionnaire, investigating the knowledge and attitudes of APN students towards depression, which could be subject to bias and the participant’s ability to self-assess their own skills. In addition, the small size of APNs who chose to participate may not be a true representation of the entire population of APNs.

Another important limitation is the reliability of the DAQ. Two additional studies (Haddad, Walters, & Tylee, 2006; Norton, Pommie, Cogneau, Haddad, Ritchie, & Mann 2011) have shown this instrument to be inconsistent, confirming the finding that the internal consistency of the DAQ and its subscales are low. The DAQ may be in need of a revision, and/or this study needs to be replicated with a larger, random sampling of APN students, and with an instrument that can prove greater reliability.

Generalizability

The research generalizability was limited to APN students who were enrolled in CSUSM College of Nursing Family Nurse Practitioner program or SDSU Adult/Gerontology or Women’s Health Nurse Practitioner Programs.

Implications for Nursing Practice

This research adds to the body of knowledge by confirming that APN students have a positive attitude towards managing depression and are comfortable discussing depression related information with

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their professional associates. It also adds to nursing’s body of knowledge by correlating a APNs age with increasing positive attitudes. However, correlating an individual’s age with their comfort level of depression management is not going to be helpful for future practice, unless education initiatives for the younger APN nurse are started.

There is not sufficient evidence that changing policies or implementing additional educational strategies will change the knowledge and attitudes of APN students towards depression. However, there is growing acknowledgement that primary care is the key component of managing mental health disorders. This is combined with previous research indicating a need for additional mental health education, as well as a stated desire for more depression education by primary care providers. PCP’s remain one of the first contact for patients when their depression becomes too much to handle. Research has shown that PCP’s often lack the appropriate training and are not comfortable assessing for depression. Research has also shown they have difficulty accessing or referring to mental health specialists. APN education and training initiatives in primary care will be vitally important to improving the treatment and knowledge of depression management. It is therefore important to increase educational strategies in graduate education, to increase the comfort and skill level for APN’s in depression management.

Recommendations for Future Research

This study was a very small, and limited in its population. Additional research should look at a larger population of APN students. Since the majority of primary care patients would prefer to be treated by their primary care provider, it is imperative that APN’s have the appropriate knowledge and attitudes to do so. Developing more effective strategies to translate knowledge into improved care, and evaluating the efficacy of APNs in delivering mental health services is an important area for future research.

Future research should focus on orienting educational efforts to improve knowledge and attitudes towards depression, then reassessing changes over time. Self-efficacy can further be used as a foundation for determining additional research on changing self-efficacy perception to positively affect participation in addressing depressive symptoms.Lastly

,

further investigation of the DAQ to include more reliability is important if this instrument is going to continue to be used.

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Summary

Depression is the most common psychiatric disorder presented in primary care settings. If diagnosed appropriate and treated, patients can improve quickly. Diagnosis of depression and its

management depends on several factors, one of the most important being the attitudes towards depression by the provider. This study was able to determine that APN students have a generally positive attitude towards depression and that with increasing age comes increased positive attitudes towards depression. In addition, participants demonstrated a positive attitude towards discussing depression related information with other health care providers. Unfortunately, this study was unable to determine APN student knowledge of depression, however previous research shows there is an additional need for increased knowledge among primary care providers. Additional graduate education would be viable, with additional studies assessing for knowledge and attitudes pre-and post-depression management education.

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Appendix A

Depression Attitude Questionnaire (modified)

1. Demographic Information Age _______________ Gender _______________ Years of practice _______________ Current specialty _______________ Ethnicity _______________

Current graduate program _______________ Number of Clinical hours completed _______________

2. People with poor stamina deal with life problems by becoming depressed

Strongly Disagree Disagree Agree Strongly Agree

3. It is difficult to know if patients are unhappy or have a clinical depressive disorder

needing treatment.

4. I feel comfortable dealing with depressed patient’s needs

5. Depression is a patient response which cannot be changed.

6. Becoming depressed is a natural part of being old.

7. Working with depressed patients can be difficult.

8. It is rewarding to spend time looking after depressed patients.

9. There is little to offer depressed patients who do not respond to what primary care

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10. Psychotherapy tends to be unsuccessful with depressed patients.

11. Depressed patients needing antidepressants are better off with a psychiatrist than

with a primary care provider.

12. Antidepressant treatment in general practice usually produces a satisfactory result.

13. If psychotherapy was freely available, it would be more beneficial than

antidepressants for most depressed patients.

14. The majority of depression seen in general practice originates from patients recent

misfortunes.

15. It is possible to distinguish two main groups of depression: one psychological in

origin and the other caused by biochemical mechanisms.

16. Depressed patients are more likely to have experienced deprivation in early life than

other people.

17. Most depressive disorders seen in general practice improve without medication.

18. Nurse practitioners have an important role in the identification and management of

depression.

19. Psychotherapy for depressed patients should be left to a specialist.

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20. Depression reflects a characteristic response in patients which is not amendable to change.

21. I am comfortable assessing for depression

22. I am comfortable in planning evidence-based interventions for an adult.

23. I am comfortable discussing depression related information with other health care

providers.

24. Most depressive disorders improve without intervention.

`25. I would know who to refer to if a person needed further assessment or treatment for

depression.

26. Patients with identified symptoms of depression should be receiving medication as

their primary treatment.

27. An underlying biochemical abnormality is the basis of severe depression.