Mental Health Aspects of the Thesis Writing Experience in Nursing

A diverse array of personal, social, environmental, systematic and academic factors have been identified as significant in the successful completion of the thesis writing process. The expanded needs for graduate level nurse practitioners demands that nursing students receive support and sustain motivation to complete their graduate study in order to fill the critical needs for advanced practice nurses across a variety of patient care sectors and populations."

Introduction

A Master's degree prepares nurses for advanced practice roles, including the management and delivery of primary health care, case management, education and administration (Hegyvary, 1992). Growing specialization by physicians, the health system's increasing demand for front-line primary care, and the accelerating drive toward managed care, prevention, and cost-efficiency are spurring a global need for nurse practitioners, certified nurse-midwives, nurse educators, and other nurses with advanced practice skills.

The American Association of Colleges of Nursing (AACN) (1997) has predicted an under-supply of Master's and Doctorally prepared nurses for advanced practice, teaching, and research. The average nurse is currently forty plus years old, a fact that is predicted to produce serious nursing shortages as retirements of large cohorts occur. Indeed, the federal Division of Nursing has recommended that at least two-thirds of the basic nurse workforce have at least baccalaureate or higher degrees in nursing by the year 2010 (National Advisory Council on Nurse Education and Practice, 1996). By the year 2000, the need for Master's and Doctorally prepared nurses for advanced clinical specialties, teaching, and research will be nearly triple the supply. That year, some 140,300 full-time-equivalent RNs with Master's and Doctoral degrees will be in the workforce, compared to the anticipated need for 392,000 (AACN, 1997).

The literature shows a need for more studies focused on the experience of successful completion of Master's theses in nursing and in other disciplines. The Master's thesis is designed to serve as a "practice exercise" for a doctoral dissertation. The essential requirement of a Master's thesis is that it literally demonstrate mastery in the student's sub-field.. James (1998) explained that the most common terms used to evaluate a thesis or dissertation were "originality, logical coherence, critical evaluation, awareness of alternatives, breadth of perspective and balanced synthesis" (p. 95).

Many graduate students are adequately trained in basic research skills, but many do not fully understand how to do thesis tasks such as reading analytically and synthetically or writing discursively. They may begin their thesis with enthusiasm, unaware that they are only rudimentarily equipped with the "basic" skills of critical reading, writing, and renumeration.

When students work on a thesis with undeveloped "basic" skills they are likely to encounter one problem after another. Eventually, an alarming number of students erroneously conclude they are not capable of completing a thesis and drop out. In truth, thesis "basics" are anything but basic. Reading is not simply identifying and interpreting words and sentences but analyzing, criticizing, and deriving implications from the literature. Writing is not just composing well-formed paragraphs but clarifying and constructing concepts and synthesizing themes that justify the study. And thinking is more than remembering and relating ideas, it is abstracting patterns and generating original insights. The thesis is a learning task to painstakedly teach students the highest scholarly skills, (Levine, 1999).

The demands of thesis writing seem to introduce a significant amount of pressure, stress, and impacts on Master's students' self-image, motivation, and ability to persevere. Mental health stability is jeopardized unless supportive and self-initiated coping behaviors are strong.

An examination of the findings from various studies devoted to the mental health implications of thesis writing can help nurses face this challenge forearmed with pertinent theory and strategies for coping with the thesis writing process.

Framing the Problem

A diverse array of personal, social, environmental, systematic and academic factors have been identified as significant in the successful completion of the thesis writing process. A closer look at these multiple factors in relation to the mental health of Master's level nursing students can contribute to educational nursing theory and knowledge. The expanded needs for graduate level nurse practitioners demands that nursing students receive support and sustain motivation to complete their graduate study in order to fill the critical needs for advanced practice nurses across a variety of patient care sectors and populations.

To further develop knowledge about the mental health needs and characteristics of graduate level nursing students, a meta-analysis study to synthesize the results of existing studies related to the mental health aspects of thesis writing for student nurses would be ideal. This data could be valuable for nursing administration, faculty and students to further understand the experience, needs, and characteristics which contribute to and ensure the successful completion of a thesis to meet the requirements for graduation from a Master's program in nursing.

A meta-analysis study on the mental health aspects of thesis writing in nursing would be quite straight forward to implement. Necessary equipment is minimal, and no intrusion on patients or students would occur. The results could provide a cohesive picture of the experience and psychological challenges faced by student nurses striving to attain graduate level degrees and meet the current demand for highly educated, research - efficient advanced nurses.

Literature Review and Conceptual Framework

The Thesis Writing Process

Literature that details the process and challenges of planning, approving, and implementing a Master's thesis is relevant to this topic to help clarify the tasks and steps involved in the final requirements for a graduate degree in nursing. Scholarship in nursing relates to activities that systematically advance the teaching, research, and practice of nursing through rigorous inquiry that a) is significant to the profession, b) is creative, c) can be documented, d) can be replicated or elaborated, and d) can be peer-reviewed through various methods (Glassick, Huber, & Maeroff, 1997; American Association of Colleges of Nursing, 1999a). With such stringent requirements, it seems essential that students be genuinely excited about the research projects they select. The successful completion of a Masters program is difficult enough when students are enthusiastic about their research project. Selecting questions and paradigms that students find only moderately interesting can convert a difficult task to an overwhelming one. Advisors and fellow graduate students can offer their opinions about the relative merits of various projects, but only the student who plans to conduct the work can decide whether a project is suitable for them (Lanyon, 1995).

Personal Coping Mechanisms

Studies that focus on personal coping characteristics and patterns in graduate students are relevant to this study, to attain a clear picture of the complexities of nursing student's hardiness, resourcefulness, and ability to persevere through the thesis writing process. Some of the factors that will be looked at include anxiety and stress management, financial factors, multiple roles, isolation and support issues, and personality characteristics.

Anxiety and Stress Factors

Lazarus (1966, 1977) argued that a person's perceptions play a substantial role in what some may call objectively stressful events. This perspective assumes that stress occurs when both (a) the situation is appraised as challenging or demanding and (b) insufficient resources are available to cope with the situation. Roche - Singh (1994) examined three general perspectives in graduate students: (a) how they perceived their academic responsibilities, (b) how they perceived their university environment, and (c) how they perceived their financial and familial responsibilities.

Stress has long been regarded as a common part of the graduate school experience. Comparing medical, law, psychology, and chemistry graduate students, Heins, Fahey, and Leiden (1984) concluded that perceived stress seems to be related to any type of graduate work. Stress in graduate school has been correlated with poor academic performance, coping problems, poor family relations, and dropping out of graduate school ( Mallinckrodt, Leong, & Fretz, 1983; Mallinckrodt, Leong, & Fretz,1985). Less evident in the research literature, however, is the lower quality of life that graduate students may experience (Saunders & Balinsky, (1993).

Common areas identified as highly stressful included class assignments, homework, finances, and thesis preparation. The implication for practice is that graduate nursing students need guidance and coping strategies to reduce stress levels (Steyn, 1998).

Financial Factors

Although full-time students can complete some Master's-degree programs in 12 to 18 months, working part-time students may take three years or more to graduate. A study by AACN in 1990 found that Master's students in nursing are solely responsible for 67 percent, and doctoral students for 84 percent, of their education financing (AACN, 1999b). Walpole (1998) found that, especially during the thesis writing process, students from low-socioeconomic (SES) backgrounds worked more, had more academic difficulties, and were less likely to pursue leadership positions with student organizations than their high-SES peers. They also felt isolated and alienated as low-SES students on a campus where the majorityof their friends

Cates (1992) equated socioeconomic status with microcomputer ownership, which his study suggested correlated with higher academic achievement by graduate students. The primary thesis functions of word-processing, data collection, tabulation and analysis, as well as tables and graphs could be worked on more carefully and leisurely when students had a computer in their own home.

Multiple Roles

Despite higher enrollments of full-time Master's students, there continues to be a concentration of Master's degree nursing students (66 percent) in part-time study (AACN, 1999b). Though part-time Master's enrollments have declined significantly across the past five years, their levels remain a key concern to nursing educators. "Although Master's tracks also prepare needed nurse administrators and educators, the largest number of Master's students are pursuing study in advanced practice programs that prepare nurse practitioners, certified-nurse midwives, clinical nurse specialists, and nurse anesthetists. At the same time as the health system is experiencing mounting demand for these advanced clinicians, part-time study is greatly delaying their entry into the RN workforce," (AACN,1999b, p. 1).

Because part-time enrollment is often associated with extracurricular roles such as marriage, parenthood, and employment, it is reasonable to predict that it is also associated with role stress, (Potts, 1992). On the other hand, multiple role enactment may be associated with a variety of benefits, such as exposure to diverse resources for tangible and emotional support. Given a finite sum of role resources, fulfillment of some obligations lessens the ability to fulfill other obligations, thus role overload occurs. Potts (1992) theorized that students faced with the need to allocate energies and skills to reduce role strain tended either to avoid enacting certain roles or engage in a series of "role bargains." Through these role bargains, individuals demand as much as possible from role enactment yet invest as little as possible themselves. Students who enact multiple roles experience more role-related stress, and thus poorer psychological adjustment than do individuals who enact fewer roles. As well, the characteristics of roles tend to differ according to whether the roles are enacted by men or women. Although both men and women may enact marital, parental, and occupational roles, expectations and pressures accruing to such roles seem to differ by gender.

Patchner (1983) found that part-time students scored higher than full-time students on a variety of indicators of stress (family, job, academic, and financial), although no differences were noted in personal and interpersonal stress. Kramer, Mathews, and Endias (1987) showed that part-time students experienced more stress than full-time students because of both school-related and external factors; however, the two groups were similar with respect to behavioral and somatic indicators of stress.

In her 1998 study, Stern found that women in the youngest age group (23-29) scored significantly higher than the middle age group (30-39) on the Impact of Graduate Studies on Lifestyle, Experience of Graduate School Training, Program Support, and Motivation indices. Motivation factors were rated as very significant by all participants. Participants with higher levels of multiple role involvement experienced greater satisfaction with graduate training, less stress from graduate studies, but higher intensity of negative impact on lifestyle than women with less involvement in multiple roles. Married women scored higher on social support than unmarried women and married women without children indicated the most willingness to utilize university-based support services. Women with children between the ages of 8-19 scored highest on relationship stress and concern about child-related issues.

Today's female graduate student enters the academic arena with anticipation, visions of self-fulfillment, and hopes of increased professional and personal credibility, only to be confronted with the stressful reality of negotiating multiple roles. In exploring the adult education process, we realize that most graduate students regardless of gender have multiple roles to juggle and that the adult student population does not seem to reduce ordrop other roles to become students. Although studies addressing the experiences of male graduate students are scarce, for women especially with a family, it means a radical change in their way of life. Nursing students, even at the graduate level, are still primarily female. Studies indicate that the stress and isolation of graduate school correlates with poor academic performance, coping problems, poor family relations, and ultimately dropping out of graduate school (Younes and Asay, 1998).

Isolation Factors

Problems of isolation represent one issue which recurs within the literature on the problems experienced by postgraduate students. These problems occur largely because of the very different way in which postgraduate research students undertake their studies compared with undergraduate students or course work postgraduate students. Most often, graduate nursing students work intensively with one or more academics and often have limited contact with other students. Even when contact among peers does occur, the individual nature of their experiences and the specificity of the research projects in which they are engaged mean that the sense of isolation often persists (Johnston, 1995).

Personality Characteristics

Graduate students vary in their level of self-efficacy beliefs and in their perceptions of their research environments while conducting thesis research (Philips and Russel, 1994). A Master's level student's research self-efficacy is often a function of a positive and nurturing research environment and a strong supervisory relationship with an advisor-mentor, (Rakow, 1998). Motivational factors, as well as the ability to conceptualize and operationalize the thesis content also contributed to the promotion of tenacity to complete the thesis, and to graduate (Homma, 1998). Koslowsky (1993) found a correlation between student intention and commitment or investment and attrition rates in higher education.

Negative cognition and overload seem to be major issues for students as well. Overload seems to be particularly important for older students, women, and those who reported multiple roles (working full-time and having significant responsibility at home). Negative cognition was important in distinguishing between stressed and non-stressed students regardless of sex or age and for those with the out-of-school demands of significant home responsibility and full-time work (Saunders & Balinsky, 1993). Leong, Mallinckrodt , & Kralj, (1990) noted differences between the level of stress perceived by Asian and Caucasian graduate students. Caucasian students reported a higher level of drug and alcohol usage in times of stress, while the Asian students reported more episodes of memory impairment, hallucinations, and paranoia.

In a study with 101 psychology graduate students, Gerson (1998) found that female students were found to score higher on hardiness than male students; students who regarded their financial situation as good scored higher on hardiness than those who regarded their financial situation as fair or poor; minority students reported more stress than white students; and employed students reported experiencing more stress than students who were not employed.

Jiao and Onwuegbuzie (1998) described how library-anxious students tended to feel that other students were adept at using the library, whereas they alone were inept, and that their incompetence was a source of embarrassment and consequently should be kept hidden. These socially prescribed perfectionists, who typically had an external locus of control and low levels of intrinsic motivation were reluctant to seek help from librarians for fear of having their perceived ignorance exposed. The work of Kluever and Green (1998) indicated that a balance must exist between the extent of one's personal forces exerted toward thesis completion and the external forces that affect it. External support systems from advisors and family, financial support, and reasonable time commitments for other activities affected thesis completion positively, and the absence of them negatively affected it.

Summary

A cohesive summary of the myriad of factors affecting the success of future advanced nursing experts helps to identify the variables which need to be considered and addressed to facilitate recruitment, retention, and successful completion of graduate degrees in nursing. Identification of the mental health needs and dynamics of graduate nursing students is the first step in the examination and implementation of supportive strategies to ease the thesis writing and learning process within Master's of Nursing programs.

References

American Association of Colleges of Nursing. (1997). A Vision of Baccalaureate and Graduate Nursing Education: The Next Decade. Washington, DC: Author.

American Association of Colleges of Nursing. (1999a). Position Statement on defining Scholarship for the Discipline of Nursing, Washington, DC: Author.

American Association of Colleges of Nursing. (1999b). Nursing School Enrollments lag behind rising demands for RNs, AACN survey shows. Washington, DC: Author.

Dempsey, P. & Dempsey, A. (1996). Nursing Research: Text and Workbook., 4^th ed. Boston: Little, Brown & Co.

Gerson, M. (1998). The relationship between hardiness, coping skills, and stress in graduate students. UMI Published doctoral dissertation. Adler School of Professional Psychology.

Glassick, C., Huber, M., & Maeroff, G. (1997). Scholarship assessed: Evaluation of the professoriate. San Francisco, CA: Jossey-Bass.

Hegyvary, S. (1992). Educating nurses for new practice environments. In C. Everts, P.P. Bottomworth & M. Osterweis (Eds.), Human Resources for Health: Defining the Future (pp. 133-140). Washington, D.C.: Academic Health Centers.

Heins, M., Fahey, S. N, & Leiden, L. (1984). Perceived stress in medical, law, and graduate students. Journal of Medical Education, 59, 169-179.

Homma, M. (1998). Synthesis of Graduate studies and life experiences by doctoral students in education. UMI Published doctoral dissertation: University of Minnesota.

James, P. (1998). Progressive Development of deep learning skills through undergraduate and postgraduate dissertations. Educational Studies, 24 (1), p95 - 106.

Jiao, Q. G. & Onwuegbuzie, A. J. (1998). Perfectionism and Library Anxiety among Graduate Students.Journal of Academic Librarianship, 24 (5),p365 - 372.

Johnston, S. (1995). Building a sense of community in a research Master's course. Studies in Higher Education, 20 (3) October, 279 - 291.

Kluever, R. C. & Green, K. E. (1998). The responsibility scale: A research note on dissertation completion.Educational & Psychological Measurement, 58 (3), 520 - 531. <

Koslowsky, M. (1993). A comparison of two attitude - behavior models for predicting attrition in higher education. Journal of Applied Behavioral Science, 29 (3), September, 359 - 366.

Lanyon, S. M. (1995). How to design a dissertation project. Bioscience, 45 (1), 40 - 43.

Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw-Hill.

Lazarus, R. S. (1977). Psychological stress and coping in adaptation and illness. In S. J. Lipowski, D. R. Lipsi, & P. C. Whybrow (Eds.), Psychosomatic medicine: Current trends (pp. 14-26). New York: Oxford University Press.

Leong, F. T. L., Mallinckrodt , B. & Kralj, M. M. (1990) Cross - Cultural variations in stress and adjustment among Asian and Caucasian graduate students Journal of Multicultural Counseling & Development, 18 (1), 19 - 29.

Levine, S. J. (1999). Writing and presenting your thesis or dissertation. East Lansing, MI: Michigan State University. Available Online: WWW: http://www.canr.msu.edu/aee/dissthes/guide.htm

LoBiondo-Wood, G. & Haber, J. (1998). Nursing Research: Methods, Critical Appraisal, and Utilization, 4^th ed. St. Louis, Mi: Mosby.

Mallinckrodt, B. S., Leong, F. T. L., & Fretz, B. R. (1983). Stress management support and resource groups for graduate students. (Report No. C6 017255). College Park, MD: University of Maryland, Psychology Department. (ERIC Document Reproduction Service No. ED 240 426)

Mallinckrodt, B. S., Leong, F. T. L., & Fretz, B. R. ( 1985). A stress management program for graduate students. Journal of College Student Personnel, 26(5), 471.

National Advisory Council on Nurse Education and Practice. (October 1996). Report to the Secretary of the Department of Health and Human Services on the Basic Registered Nurse Workforce, p. 9. Washington, DC: Division of Nursing, Health Resources and Services Administration.

Patchner, M. A. (1983). The practitioner becomes a student: The stresses of transition. Journal of Continuing Social Work Education, 2, 21-23, 31.

Phillips, J. C., & Russell, R. K. (1994). Research self-efficacy, the research training environment, and research productivity among graduate students in counseling psychology. The Counseling Psychologist, 22, 628-641.

Potts, M.K. (1992). Adjustment of graduate students to the educational process: Effects of part time enrollment and extracurricular roles. Journal of Social Work Education, 28 (1) Winter,p61 - 77.

Rakow, E.A. (1998). A Study of factors related to dissertation progress among doctoral candidates: Focus on student research self-efficacy as a result of their research training and experiences. UMI Published doctoral dissertation: The University of Memphis.

Rocha - Singh, I. A. (1994). Perceived stress among graduate students: Development and validation of the graduate stress inventory.Educational & Psychological Measurement, 54 (3), p714 - 728.

Saunders, R. P. & Balinsky, S. A. (1993). Assessing the cognitive stress of graduate students. Measurement & Evaluation in Counseling & Development, 26 (3), October, 192- 204.

Stern, L. S. (1998). The Experience of Women combining roles and graduate training in Counseling Psychology>. UMI Published doctoral dissertation: Loyola University of Chicago.

Steyn, L. M. (1998). Identifying stress levels of students and stressful components of a graduate social work program. UMI Published Master's Thesis: California State University, Long Beach.

Younes, M. N. & Asay, S. M. (1998). Resilient women: How female graduate students negotiate their multiple roles.College Student Journal, 32, (3), 451 - 463.