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Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 140-147

The Impact of a “Brief ECT Orientation Module” on the knowledge and attitude of nursing students toward electroconvulsive therapy

Department of Psychiatry, Government Medical College, Surat, Gujarat, India

Date of Submission08-Jan-2020
Date of Decision01-May-2020
Date of Acceptance24-May-2020
Date of Web Publication25-Nov-2020

Correspondence Address:
Dr. Zainab Zuber Panwala
Flat No. 501, Zamzam Park Society, Lohar Sheri No.1, Sagrampura, Surat, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_2_20

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Context: Despite the proved effectiveness of electroconvulsive therapy (ECT) in the treatment of many psychiatric emergencies and disorders, ECT continues to be an intervention that attracts controversies. There are limited literature on attitude and knowledge of nursing students toward ECT from India. Aims: The aim was to explore the impact before and after Brief ECT Orientation Module on the knowledge and attitudes toward ECT among nursing students. Study Design: Pre- and post-study design. Subjects and Methods: Nursing students who had completed their psychiatric rotation were assessed using knowledge and attitude questionnaire before and after exposure to 1 h lecture, video representing the ECT procedure, and live demonstration of ECT. Informed consent was obtained from students who agreed to participate in the study. Statistical Analysis Used: Data analysis was done using SPSS version 17.0 SPSS Inc., Chicago, Ill., USA. The impact of Brief ECT Orientation Module on knowledge and attitude of nursing students was assessed by comparing the baseline score on the study questionnaire with the post module scores using student paired sample t-test and Chi-square test. Level of statistical significance was kept at P < 0.05 for all the tests. Results: Majority of the students had average knowledge about the effectiveness, mechanism of action, indications, consent, and side effects of ECT. There was a significant improvement seen toward all domains of the questionnaires post ECT module. Conclusions: Findings of the current study suggest that Brief ECT Orientation Module is effective in improving the knowledge and attitude of nursing students toward ECT.

Keywords: Attitude, Brief ECT Orientation Module, nursing students, knowledge

How to cite this article:
Panwala ZZ, Dadarwala DD, Mehta RY. The Impact of a “Brief ECT Orientation Module” on the knowledge and attitude of nursing students toward electroconvulsive therapy. Ann Indian Psychiatry 2020;4:140-7

How to cite this URL:
Panwala ZZ, Dadarwala DD, Mehta RY. The Impact of a “Brief ECT Orientation Module” on the knowledge and attitude of nursing students toward electroconvulsive therapy. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Apr 20];4:140-7. Available from: https://www.anip.co.in/text.asp?2020/4/2/140/301427

  Introduction Top

Electroconvulsive therapy (ECT) involves the induction of a grand mal seizure through the passage of an electrical current to the patient brain with the aim of improving the patients' mental status under anesthesia and muscle relaxant.[1] ECT is widely prescribed worldwide and first indicated in the emergency treatment of severe depression with suicide or psychosis and medication-resistant schizophrenia.[2] The effectiveness of ECT in the treatment of depression was established in 1941.[3] The introduction of psychopharmacology in the 1970s and 1980 reduced the use of ECT in the treatment of mental illnesses.[4]

Despite the documented effectiveness of the ECT in the treatment of symptoms of depression,[5] from the prospective of many professionals and public, ECT still remains controversial and stigma bound. Attending the live treatment session plays significant role in forming attitudes toward ECT, while viewing movies' clips that portraying ECT as an inhuman and brutal method generates a more negative attitude toward ECT.[6] Previous studies have shown that a brief supplementary education program in addition to the traditional curriculum can lead to significant improvement in the knowledge and attitude of students and health professionals toward the mentally ill and mental illnesses.[7],[8],[9],[10],[11],[12],[13],[14],[15]

Today's nursing students are tomorrow's nurses who will be closely working and taking care of the patients. The nature of nursing profession requires nurses to spend more hours with the patients than all other health-care professionals and considering the valuable and essential nursing interventions provided to the patients undergoing ECT prior, during and after the treatment session; therefore, nurses' knowledge and attitudes toward ECT will impact their patients' knowledge and attitudes toward ECT.[16] Literature review reveals several studies exploring nurses' knowledge and attitudes toward ECT.[16] It has been suggested that there is a positive relationship between years of clinical experience and knowledge of mental health professionals regarding ECT and their attitudes toward ECT, while poor contact with ECT during students training was connected to poor knowledge and more negative attitudes.[16],[17]

The aim of the present study was to explore the impact before and after Brief ECT Orientation Module on the knowledge and attitudes toward ECT among nursing students.

  Subjects and Methods Top

The study was conducted at a tertiary care multispecialty civil hospital associated with government medical and nursing college. Nursing college runs undergraduate program in BSc and GNM nursing education. Third year and final year BSc nursing student and 2nd year and 3rd year GNM nursing students among whom psychiatry comes as a subject in syllabus and who finished their psychiatric rotation were taken in study. Ethics committee approval and permission from the principle of nursing college, matron, and dean was taken.

All 3rd year and final year BSC students and 2nd year and 3rd year GNM nursing students were explained about study design, nature, and need of study, and those willing to participate and gave informed consent were considered eligible. Participation was voluntary. Written informed consent was taken in the language that they understand after giving “Participant Information Sheet,” queries were answered, and “Participant Informed Consent Form” was duly filled and signed by nursing students. Nursing students were interviewed for demographic data and related details using a semi-structured pro forma specifically designed for the study. Baseline knowledge was evaluated using knowledge questionnaire which has 38 questions which cover various aspect of ECT such as procedure, informed consent, efficacy, usefulness, and side effect of ECT.

Brief ECT Orientation Module

The “Brief ECT Orientation module” was delivered. A brief module was formulated to avoid it from becoming highly time intensive and, consequently, less interesting to the students. The program was designed to provide comprehensive information regarding ECT using a variety of educational modes.

  1. Powerpoint presentation: approximately 1 h session covering the titles shown in [Table 1]
  2. Exposure to an educational videotape that include ECT information and seeing a patient on screen undergoing ECT and videos demonstrating the difference between unmodified and modified ECT
  3. Live demonstration of ECT procedure. Preparation of equipment and medication needed for patient undergoing ECT session (was done during their clinical rotation).
Table 1: Learning objectives covered in power point presentation of ECT

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Post-ECT orientation module, knowledge, and attitude were re-evaluated using same questionnaire. Confidentiality and anonymity was ensured by using identification codes on questionnaire that facilitate individual comparison of pre- and post-educational program responses.

Study questionnaires

Data were designed using a modified version of the questionnaires on the knowledge of and attitudes toward ECT.[18],[19] The initial part of the questionnaire included questions regarding students' age, sex, whether they are in BSC or GNM, 2nd/3rd/final year, sources of information about ECT, and if the nurse student had any personal experience with a person with a diagnosis of mental health problem other than from the clinical setting.

The 1st item of questionnaire inquired about primary source of information regarding ECT among nursing students such as Internet, newspapers, magazines, books, lectures, movies, and discussion with friends and family members. The second part of the questionnaire consisted of a total of 38 items aimed at assessing the knowledge of the students about indications (5 items), procedure (12 items), adverse effects (10 items), mechanism of action (8 items), and informed consent (3 items) of ECT. The students were expected to mark the items as yes, no, or don't know in majority of the questions. The final score was calculated by summing up the number of correct responses in each of the five domains separately. The third part of the questionnaire comprised of 17 items aimed at the assessment of attitudes of nursing students toward ECT. The students were expected to mark their responses as “Agree,” “Disagree,” or “neutral “to the individual items.

Content validity of the instrument was assessed by two experts who examined the tool and approved it. The participants needed 15–20 min to complete the questionnaire. A pilot study was conducted to test the feasibility and applicability of the tool. The pilot study was carried out on five participants. The result of the pilot study was helpful in refining the questionnaire form.

  Results Top

A total of 115 nursing students posted for their clinical rotation in the Department of Psychiatry were approached for participation in the study. All of them agreed to participate in the study. The study had 100% completion rate. The mean (standard deviation) age of the students included in the study was 19.16 years. Out of which, 100 were females and 15 were males; 67 were BSC Nursing students and 58 were GNM students. Those coming from urban background (n = 84; 73%) outnumbered those from rural background (n = 31; 27%).

Regarding the sources of knowledge about ECT, almost all of them had witnessed ECT directly and had read books (n = 115, 100% and n = 112, 97.4%, respectively) followed by lecture (n = 45, 39.1%) and the Internet (n = 30, 26.1%). Discussion with friends and family members, magazines, and newspapers were least frequently referred as the source of knowledge. Two students gained information regarding ECT from a personal experience of relatives or friends treated with ECT [Table 2].
Table 2: Sources of students' knowledge about electroconvulsive therapy (n=115)

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Prior to attending the Brief ECT Orientation Module, only 39.1% had attended lecture on ECT during their academic sessions, and all of them (100%) had witnessed ECT being administered to patients during their clinical rotation. After completion of the Brief ECT Orientation Module, all the students attended a lecture on ECT.

Knowledge about electroconvulsive therapy in nursing students

Impact of Brief ECT Orientation Module on knowledge about electroconvulsive therapy among nursing students

On the knowledge questionnaire, majority of nursing students had correct baseline knowledge about mechanism of action of ECT, adverse effects, and consent procedure. Overall, there was improvement in the knowledge of nursing students on all the five domains of the questionnaire for the assessment of knowledge about ECT-related facts (procedure, indications, mechanism of action, side effects, and consent) after Brief ECT Orientation Module; but, knowledge in two domains, procedure and indications, was found significantly improved (P <0.001 and P <0.001, respectively).

As shown in [Table 3], after clinical rotation, almost all nursing students had knowledge about the basic facts such as investigations are necessary, anesthetic medications are given before the procedure, current is applied on scalp for few seconds, and psychiatrist can administer ECT. However, only three-fourth were aware that ECT can be given more than once per week (n = 81, 70%). Similarly, only half of them knew that ECTs could be given more than six in one course (n = 70, 60.8%) and patient is unaware of what is happening during ECT procedure (n = 66, 57.3%). Less than one-fourth were aware that patient experiences convulsion during ECT (n = 19, 16.5%). Lack of knowledge in nursing students in these certain aspects about the procedure of ECT despite attending clinical rotation and lectures, improved significantly after Brief ECT Orientation Module.
Table 3: Responses on knowledge of electroconvulsive therapy procedure pre- and post-Brief ECT Orientation Module among nursing students (n=115)

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In terms of indications for ECT, overall basic knowledge was poor despite attending clinical rotation as shown in [Table 4]. Only about half or lesser number of nursing students were aware that ECT is not given to only those who have little chance to improve (n = 68, 59%) and pregnant women can also receive ECT (n = 52, 45%). Only two-third knew that ECT can also be given to elderly ≥60 years (65%) and can be given to outpatient also (n = 75, 66%). However, knowledge about indications for ECT at the end of Brief ECT Orientation Module was significantly better as compared to baseline score (P <0.001).
Table 4: Responses on knowledge of Indications of electroconvulsive therapy procedure pre- and post-Brief ECT Orientation Module among nursing students (n=115)

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In terms of effectiveness and mechanism of action for ECT as shown in [Table 5], overall basic knowledge of nursing students was good. Majority of them knew that ECT is useful in treating psychiatric disorder (n = 107, 93%), compared to medications, ECT is more useful and effective (n = 106, 92%) scientific evidence favors usefulness of ECT (n = 101, 88%) and how does ECT work (n = 107, 93%). Whereas, less than three-fourth knew that effect of ECT is not permanent (n = 69, 60%) and only three-fourth were aware that ECT does not worsen psychiatric illness (n = 88, 76%). However, at the end of Brief ECT Orientation Module, knowledge about effectiveness improved significantly (P = 0.001).
Table 5: Responses on knowledge of mechanism of action of electroconvulsive therapy procedure pre- and post-Brief ECT Orientation Module in nursing students (n=115)

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As shown in [Table 6], before ECT module, majority of the nursing students had correct knowledge that ECT does not cause burn or permanent damage to brain or other body parts (n = 103, 89%), temporary memory loss (n = 102,88.69%), and chances of death is very rare (n = 105, 91.3%). However, few students knew that most of patients receiving ECT develop epilepsy later in life (n = 78, 67%); there was a significant improvement post module (P = 0.000).
Table 6: Responses of side effects of electroconvulsive therapy procedure before and after the Brief ECT Orientation Module (n=115)

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Majority were aware of the fact that ECT cannot be given against wish of patients and the family member (n = 102, 88.6%) and that written permission of the patient or his/her family member always necessary (n = 111, 96.5%). On the contrary, very few knew that among family, friends, and psychiatrist; close family can decide and give consent if someone is advised ECT (n = 20, 17.3%); but this knowledge improved and got corrected significantly post module (P = 0.000) [Table 7].
Table 7: Response of informed consent for ECT before and after the brief ECT Orientation Module with P value (n=115)

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As shown in [Table 8], on 10 out 17 items, more than 3 / 4th participants had positive attitude; on 4 out of 17 items, around half of them had positive attitude. On item no. 6, nearly half of them had disagreed that ECT should only be used as a last/worst treatment choice, this positive attitude increased further to (80.87%) after module. Post ECT module almost all (100%) agreed that ECT should not be banned (P = 0.000). Also, more than 3 / 4th had agreed close relatives to receive if recommended which this positive attitude increased further to 90% post module, (P = 0.000). On item number 9 (i.e., ECT affects thinking, reasoning, and remembering ability of patient), more than half had negative attitude, which decreased after module to 6.9% and almost 86% (P = 0.000) changed their attitude toward positivity and disagreed that ECT affects thinking, reasoning, and remembering ability of patients. On item numbers 2 and 15 (ECT is primitive/outdated method of treatment, I feel comfortable watching ECT being administered), nursing students were responses were mixed, those with negative attitude (41.7%, 41.7%) outnumbered those with positive attitude (39.1% and 33%, respectively). However, post-ECT module nursing students changed their attitude toward positivity (85%) that they will feel comfortable watching ECT being administered (P = 0.000). On the whole, not even a single nursing student had positive attitude on all the items of attitude.
Table 8: Attitude questionnaires correct responses given by students before and after Brief ECT Orientation Module along with each question's significant value (n=115)

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  Discussion Top

In the Indian setting, among the members of mental health team, nurses are most likely to be available to the patients and their relatives round the clock. They can be a potential source of information to the patients and their relatives. Accordingly, their knowledge and attitude have a significant role in coloring the knowledge and attitude of patients as well as patient's relatives. Hence, understanding their knowledge and attitude can help in identifying the areas of intervention so as to ultimately improve the acceptability of treatments such as ECT and overall outcome of patients. The best stage to address the faulty attitudes and deficient knowledge is during the formative years. Accordingly, the current study examined the knowledge and attitudes of nursing students toward ECT.

In terms of source of information, in previous studies by Warnell et al.[17] and Bawo Onesirosan et al.,[20] the key sources of students' information were movies followed by discussion in a college class and then TV programs. Media in the majority of the world represent mental illnesses and mental treatments in a more negative way, which result in poor knowledge and more negative attitudes toward psychiatry[21] and consequently toward ECT as one of the psychiatric treatment options before the educational experience. But in the current study, we found source of information to be more scientific in form of books and lectures and witnessing ECT administered during clinical posting.

Finding of our study suggest that nursing students had overall a good basic knowledge in basic aspects such as indication, procedure, side effects, mechanism of action, consent, and positive attitude toward ECT, This could be because majority of the students source of information was witnessing ECT (100%), books (97.4%), and lectures (39.1%), which is scientific and evidence based. Also, these nursing students had finished their clinical rotation. Despite basic knowledge before module being good there are certain areas such as mechanism of action, side effects, procedure, indication, and consent, in which few had deficit in knowledge. However, after our Brief ECT Orientation Module which reinforced their knowledge in deficit area and improved significantly in respective deficit area. Instead of this sentence please add another sentence as follow: However, after our Brief ECT Orientation Module their knowledge in deficit area has been significantly improved.

This finding is consistent with the study by Poster et al.,[22] who concluded that teaching nursing students using a videotape on ECT had a positive impact on nursing students' perception of ECT. Warnell et al.[17] also concluded that watching live demonstration or viewing an ECT videotape was effective ECT teaching methods for students who had positive impact on the students' knowledge and attitudes toward ECT. Szuba et al.[23] and Chanpattana[24] also observed the positive effect of psychiatry training and reinforcement in training in the form of videotapes, lectures, and live demonstration in improving the levels of knowledge about ECT among students.

Evidence suggest that fear of “unexpected side effects,” fear of procedure, and “lack of enough information” are some of the important factors, which often lead to withdrawal of consent of the patients consider for ECT.[25] Existing literature suggest that there is a positive association between knowledge and positive attitude toward ECT.[26] The finding of the current study also suggests the same.

Limitations of the study

Limitation is that we assessed the knowledge and attitudes right after the educational experience within the same session, which cannot predict students' attitudes over time.[12]

  Conclusions Top

The findings of the current study suggest that the Brief ECT Orientation Module is effective in improving the overall knowledge and attitude of nursing students toward ECT. The module is not time intensive and can be administered in a short time. It addresses both theoretical and practical aspects related to ECT.

The present study shows that knowledge and attitude toward ECT among nursing students was overall good except in some specific areas; to fill such gap, there is a need to develop reinforcing booster sessions in the curriculum which are more pro-ECT. The results of the current study signify the importance to present the up-to-date scientific basis of ECT when teaching nursing students about ECT.

Recommendations for future research and implications of study

Use of further booster sessions, especially more demonstration session of ECT administration, and interacting of nursing students with these patients at follow–up, will help to improve their attitude toward ECT.


The researchers would like to extend their thanks and appreciations to all the nursing students who agreed to participate in this study and shared their experience.

Ethical statement

This study was approved by Institutional Ethics Committee with reference number GMCS/STU/ETHICS/Approval/22418/19 obtained on28th August 2019.

Declaration of Patient Consent

Patient consent statement was taken from each patient as perinstitutional ethics committee approval along with consenttaken for participation in the study and publication of thescientific results / clinical information /image withoutrevealing their identity, name or initials. The patient is awarethat though confidentiality would be maintained anonymitycannot be guaranteed

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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McCall WV. Electroconvulsive therapy in the era of modern psychopharmacology. Int J Neuropsychop 2001;4:315-24.  Back to cited text no. 4
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Chanpattana W. ECT knowledge in psychiatrists, psychiatry residents, and medical students: Effect of training. J Med Assoc Thai 1999;82:819-25.  Back to cited text no. 15
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Chew-Graham CA, Rogers A, Yassin N. 'I wouldn't want it on my CV or their records': Medical students' experiences of help-seeking for mental health problems. Med Educ 2003;37:873-80.  Back to cited text no. 18
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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