The Effectiveness of an Educational Program on the Mental Health Literacy of Nurses Working in General Hospitals: a Controlled Trial
Phase: NA
Conditions: Mental Health Issue
Sponsor: Chinese University of Hong Kong

 
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Title: The effectiveness of an educational program on the mental health literacy of 
nurses working in general hospitals: a controlled trial 
 
Date of document: 10/06/2022 
 
 
 
 
 

 
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Background 
Mental health literacy is a concept that encompasses knowledge of mental health, mental 
illnesses, and their management; mental illness-related attitudes/ stigma; and help-seeking 
efficacy (Chao et al., 2020; Hao et al., 2020; Kutcher et al., 2016). It affects healthcare 
professionals’ ability to recognize, manage and prevent mental illnesses (Al-Yateem et al., 2018; 
Elyamani & Hammoud, 2020; Furnham & Swami, 2018; Hao et al., 2020; Kutcher et al., 2016; 
Wei et al., 2015). There is an increasing number of patients admitted to general hospitals with a 
secondary diagnosis of mental illness (Avery et al., 2020; Rice et al., 2019). Physical-mental 
comorbidity is a condition in which an individual actively suffered from both physical and 
mental illnesses at the same time (Erving, 2017; Sartorius, 2018). It affected 12-40% of patients 
in general hospitals and is becoming more prevalent around the globe (Chadda et al., 2017; 
Sartorius, 2018; Walker et al., 2018; Weichert, 2019; Zou et al., 2018). Patients with physical-
mental comorbidity had higher healthcare costs in terms of a longer average general hospital stay 
of 4.38 days (Jansen et al., 2018), and were more likely to be hospitalized for various reasons 
(odd ratio 1.16; 95% confidence interval 1.10-1.23), had more visits in the emergency 
department (odd ratio 1.26; 95% confidence interval 1.21-1.32) (Guerrero Fernández de Alba, 
Inmaculada et al., 2020) as compared to those without such comorbidity. Furthermore, physical-

 
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mental comorbidity is associated with poor patient physical and mental outcomes, and a higher 
mortality rate (Demko, 2018; Guerrero Fernández de Alba, Inmaculada et al., 2020; Rayner et 
al., 2014; Weichert, 2019). Psychiatric consultation-liaison service has been developed to address 
the mental health service needs of patients with physical-mental comorbidity in general hospitals 
(Mak and Wong, 2019).  The service reduced patients’ psychiatric symptoms (e.g., decreases 
depressive symptoms with effect size d= 0.31, 95% CI= 0.21 to 0.41), lowered mortality rates 
(e.g., coronary patients who were referred to the service had three times less likely to die 
compared those did not), and reduced patients’ length of general hospital stay (Singh et al., 2016; 
Sivin et al., 2020; Stein et al., 2020).  However, the service utilization rate in general hospitals, 
which depends on the referral from general hospital healthcare professionals, was low ranging 
from 0.72 to 5.8% (Chen et al., 2016; Kovacs et al., 2021). One of the main factors for this care 
gap is the suboptimal level of mental health literacy of general hospital healthcare professionals 
(Chen et al., 2016; Giandinoto & Edward, 2014; Grover et al., 2017). 
The suboptimal level of mental health literacy among general hospital healthcare 
professionals is common. A meta-analysis of China medical staff’s mental health literacy 
reported that general hospital healthcare professionals had the lowest awareness rate of mental 
health (68%) compared with community medical staff (82%) and psychiatric hospital staff (88%) 

 
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(Guo et al., 2021). They lacked understanding of mental illnesses and treatments and had 
negative attitudes toward patients with mental illnesses (Elyamani & Hammoud, 2020; Hao et 
al., 2020). General hospital healthcare professionals felt unprepared and had low perceived 
competency in dealing with patients’ mental illnesses in general hospitals which affected their 
care provision (Elyamani & Hammoud, 2020). They tend to prioritize physical healthcare over 
mental healthcare which affected the quality of care and patient satisfaction (Giandinoto & 
Edward, 2016; Naylor et al., 2016; Pope, 2011; Yıldırım, 2019). In a study of 288 patients with 
physical-mental comorbidity in general hospitals, over 80% of patients with active mental 
problems were not referred to psychiatric consultation-liaison service because the treating 
healthcare professionals considered it unnecessary (Weichert, 2019). Furthermore, general 
hospital healthcare professionals expressed frustration in caring for patients with physical-mental 
comorbidity and perceived the care was complex and challenging which “strains an already 
overburdened workforce” and increased their work stress (Giandinoto & Edward, 2015; Joung et 
al., 2017; Weare et al., 2019).  Indeed, there is a significant negative relationship between self-
perceived competency and work stress among hospital healthcare professionals (Prahara & 
Indriani, 2019; Vaezfar et al., 2014).  
Healthcare professionals in the general hospitals, especially nurses, are in regular contact 

 
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with patients with physical-mental comorbidity (Giandinoto & Edward, 2015). Indeed, the World 
Health Organization recommended that other than providing health services to manage physical-
mental comorbidity, health organizations should ensure general hospital healthcare professionals 
have sufficient knowledge and skills to identify patients with mental health needs and know-how 
and when to refer such patients for specialized care (Cohen, 2017). This indicated an urgent need 
to improve the mental health literacy of general hospital healthcare professionals. 
We have conducted a systematic review of randomized controlled trials to examine the 
effectiveness of the thirteen interventions in improving the mental health literacy of general 
hospital healthcare professionals. The findings showed that intervention with educational 
components can improve healthcare professionals’ mental health literacy, in terms of mental 
health knowledge and mental illness-related attitude/ stigma. In addition, an educational 
intervention targeting specific mental illnesses and tailored to the educational needs of general 
hospital healthcare professionals had a significant large effect on improving participant’s mental 
health knowledge (Cohen’s d ranges from 0.86 to 1.32) (Handmaker et al., 1999; McCrow et al., 
2014; van de Steeg et al., 2014) and the effect sustained to two months post-intervention 
(Cohen’s d=0.75) (McCrow et al., 2014). Although the content, delivery mode, duration of the 
interventions, and the measures to assess outcomes were varied in our systematic review, it was 

 
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found that a web-based approach is a viable and effective strategy to improve general hospital 
healthcare professionals’ mental health literacy. Evidence suggested that self-paced web-based 
education with an estimated time spent of 4 hours was sufficient leading to statistically 
significant improvement in participants' mental health literacy immediately after intervention 
(van de Steeg et al., 2014) and a five-week free access period to the educational material yielded 
a sustained improvement in mental health literacy to six to eight weeks (McCrow et al., 2014). 
These results were comparable to an integrative review of the effect of mental health education 
on generalist healthcare professionals (Brunero et al., 2012) and a number of quasi-experimental 
studies that evaluated the effectiveness of mental health literacy intervention for non-psychiatric 
healthcare professionals (D'Onofrio et al., 2002; Gabel & Pearsol, 1993; Graham et al., 1997; 
Karlin et al., 2017; Knaak et al., 2015; Madan et al., 2013; Sheffer et al., 2009; Smythe et al., 
2014). Indeed, web-based education provides healthcare professionals with better access to 
educational resources at their own pace and time, which is especially important in the current 
busy clinical situation and the COVID-19 pandemic (Chan & Leung, 2020; Regmi & Jones, 
2020; Vaona et al., 2018). Moreover, the systematic review of the effectiveness of the mental 
health literacy intervention for general hospital healthcare professionals found that fewer 
interventional studies examined educational intervention to enhance all components of general 
hospital healthcare professionals’ mental health literacy. To date, none of these studies had been 

 
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conducted in Hong Kong. 
Nurses are the major healthcare workforce in general hospitals for the initial identification 
of mental illness, help doctors to deal with patients’ conditions, and contribute to positive patient 
outcomes in general hospitals (Hao et al., 2020). Therefore, there is a need to develop an 
educational program focused on improving all components of mental health literacy among 
nurses working in general hospitals to address the gap in the existing literature. 
Development of the educational program 
Based on the evidence from the systematic review of the effectiveness of mental health 
literacy intervention of general hospital healthcare professionals, the education program should 
consist of self-paced web-based education, with an estimated time spent of 4 hours and allowed 
free access period of the educational material for at least 5 weeks. It is purposed that the 
educational intervention will improve mental health literacy and perceived competency in caring 
for patients with mental illnesses among nurses working in general hospitals. As such, the work 
stress of general hospital nurses and patient satisfaction with nursing care in general hospitals 
can also be improved (Yao et al., 2018). As a result, the educational program developed consists 
of six 30-minutes online educational sessions and one 60-minutes face-to-face session (Refer to 
Table 1.). 

 
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Table 1. Educational program rundown 
Online education (30 minutes in each session) 
Module 1: Mental health knowledge 
Session 1: Delirium 
The clinical manifestations, assessment principles, and 
management principles 
Session 2: Depression 
The clinical manifestations, assessment principles, and 
management principles 
Online education (30 minutes in each session) 
Module 2: Mental illness-related attitude/ stigma 
Session 3: Mental illness-
related attitude/ stigma in 
healthcare settings 
1 
The definition of mental illness-related stigma 
2 
The current situation of mental illness-related stigma in 
healthcare settings 
3 
Strategies to reduce mental illness-related stigma in 
healthcare settings 
Session 4: Mental health 
recovery journey 
1 
Definition of mental health recovery 
2 
Experiences of people with mental illnesses and their 
recovery 
3 
Role of healthcare professionals and the organizations 
in the mental health recovery journey 
Online education (30 minutes in each session) 
Module 3: Help-seeking efficacy 
Session 5: Mental illness-
related help-seeking 
1 
Barriers to the mental illness-related help-seeking 
2 
Information about how to seek help and from whom 
(formal and informal resources) 
Session 6: Psychiatric 
consultation-liaison 
service 
1 
The psychiatric consultation-liaison services in general 
hospitals 
2 
The situation warrants a referral to psychiatric 
consultation-liaison services 
3 
Referral procedure of psychiatric consultation-liaison 
services 
Face-to-face session (60 minutes) 
Problem-based learning 
Vignettes were based on the clinical scenario and were 
intended to represent patients with mental illnesses whom 
psychiatric consultation-liaison service would be helpful. 
1 
Be familiar with the principles of assessment of a 
mental illness 
2 
Be familiar with the principles of management of a 
mental illness 
Group sharing 
1 
Self-reflection on mental health literacy level and 
strategies to manage patients with mental illnesses in 
general hospitals 
2 
Discuss the way to improve the mental health literacy 
of healthcare professionals in general hospitals 
 
 

 
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In this study, the development of the educational program was guided by the concept of 
mental health literacy, and self-efficacy theory.  In addition, the program will be conducted in a 
constructivist learning environment.  
Concept of mental health literacy 
The content of the educational program is underpinned by the concept of mental health 
literacy including knowledge of mental health, mental illnesses, and their management; mental 
illness-related attitudes/ stigma; and help-seeking efficacy (Chao et al., 2020; Hao et al., 2020; 
Kutcher et al., 2016).  
Based on the literature review, the educational interventions with specific information on 
mental illnesses based on the educational need of healthcare professionals were effective in 
enhancing mental health literacy. Several studies found that the most common mental illnesses 
found in general hospitals were delirium and depression (Butler et al., 2021; Lolam & Reddy, 
2021; López-Atanes et al., 2021; Marchi et al., 2021; Scott et al., 2021; Suhaff et al., 2021). 
Therefore, online educational sessions are developed focusing on these mental illnesses with 
information about their clinical manifestations, assessment, and management.  
To improve mental illness-related attitudes/ stigma, participants will receive information 

 
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about the definition of mental illness-related stigma, the current situation of the stigma in the 
healthcare setting, related stigma reduction strategies, and patients’ stories sharing. Sharing the 
lived experiences of mental illnesses and the recovery journeys allow a better understanding of 
patients’ strengths, interests, and contributions to the community. Participants will also educate 
on the definition of the mental health recovery journey and the role of healthcare professionals in 
patients’ mental health recovery journey.  
Knowing about accessible resources was as essential as knowledge about mental illnesses in 
enhancing help-seeking intention and efficacy (Ren et al., 2020; Waldmann et al., 2020). The 
information about barriers to help-seeking and the resources available to support general hospital 
healthcare professionals in caring for patients with mental illnesses, for example, making 
referrals to psychiatric consultation-liaison services, will be included in the intervention. The 
information will highlight the situation warranting a referral to the psychiatric consultation-
liaison service, as well as the referral procedure. It was expected that participants can learn to 
locate, comprehend, and use information or services after the educational intervention, and able 
to make health-related decisions and actions for themselves and their patients that reflect 
improvements in help-seeking efficacy (Centers for Disease Control and Prevention, 2021; 
Kutcher et al., 2016). 

 
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Self-efficacy theory  
Self-efficacy refers to an individual’s perceived capability to execute behaviors to achieve 
satisfactory performance attainment (American Psychological Association, 2022; Bandura, 
1977). According to the self-efficacy theory (Bandura, 1977), self-efficacy is influenced by 
performance accomplishment, vicarious experience, social persuasion, and emotional and 
physiological states (Tay et al., 2020). The educational intervention is developed to address these 
constructs of self-efficacy.  
For performance accomplishment, through pre-and-post-questionnaires and problem-based 
learning, participants gain self-awareness in personal improvement regarding knowledge, 
attitudes, and help-seeking efficacy related to the mental health issue. In problem-based learning, 
participants can experience an enactive mastery experience when they have a chance to use new 
knowledge learned from the online educational sessions and found success in solving the 
problems in problem-based learning. They can develop new knowledge by observing others on 
how to help the patient effectively and have a deeper reflection to positively address their 
attitudes and behavior toward patients with mental illnesses (Lien et al., 2021). Participants will 
be more likely to take action to help patients with mental illnesses in the clinical setting when 
they found their choices may produce desired outcomes. For vicarious experiences, through the 

 
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online discussion forum, problem-based learning, and group sharing, participants can learn new 
knowledge by observing others’ responses to solving the problem when helping patients with 
mental illnesses. To ensure social persuasion, positive discussion in the online forum will be 
facilitated to encourage learning, positive attitude, and behavioral change in mental health issues. 
It aimed at providing participants with positive feedback on knowledge gain, attitude, and 
behavioral changes. Verbal feedback will be provided about participants’ opinions on handling 
the vignettes in the problem-based learning and influences participants to believe in their ability 
to help patients with mental illnesses in general hospitals. Compliments will be given for 
personal improvement in mental health literacy. Regarding emotional and physiological states, in 
the group sharing session, participants’ feelings and perceptions will be recognized and there will 
a chance to correct negative interpretations from facing a mental health issue. Participants can 
learn from each-others for how to manage their own emotions when facing a challenging 
situation and improve their sense of self-efficacy in helping patients with mental illnesses in 
general hospitals.  
Constructivist learning environment 
The whole program will be held in a constructivist learning environment. Participants will 
be allowed to construct knowledge individually and acquired knowledge based on their 

 
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interactions in the external world (Brau, 2018; Rannikmäe et al., 2020; Yıldız-Feyzioğlu et al., 
2013). Through pre-post questionnaires and free access to education material, participants 
proceed with cognitive constructivism by setting up individual learning goals, facilitating further 
learning according to their own needs, and having the autonomy to control their learning process. 
Through online discussion forums, problem-based learning, and group sharing, participants 
undergo social constructivism by learning in a collaborative process.  
Methodology 
Objectives 
 
This study aims to examine the effect of an educational program on improving the mental 
health literacy of general hospital nurses, in terms of knowledge of mental health, mental 
illnesses, and their treatment; attitude or stigma about mental illnesses; and help-seeking 
efficacy. It also measures the interventional effect on perceived competency in caring for patients 
with mental illness and work stress among general hospital nurses, as well as patient satisfaction 
with nursing care in general hospitals.  
Study design 
This study is a prospective 2-arm parallel controlled trial. Randomized controlled trials 

 
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were not feasible for this study because of the risk of contamination (Kahan et al., 2016). It 
would be difficult to “blind” healthcare professionals to their assigned group because they could 
easily disseminate information within and between units during clinical sharing or conversation 
at the common facilities of the same hospital, such as changing rooms and canteen. Two study 
hospitals will be assigned to the intervention arm or control arm by tossing a coin. 
Study setting 
The study sites will be conducted in the emergency departments and medical wards of two 
regional general hospitals. It was because patients with physical-mental comorbidity were mostly 
caring in this area (Weichert, 2019; Woon & Redzuan, 2019). The two hospitals are similar in 
nature and the service provided. Both study hospitals provide a comprehensive range of acute, 
rehabilitation, and ambulatory service for the people living in the western part of the New 
Territories of Hong Kong. (Pok Oi Hospital, 2022; Tuen Mun Hospital, 2022). These two 
hospitals had two emergency departments and 18 medical wards, serving about 270,000 patients 
annually and at least hundreds of nurses were working collaboratively with doctors and allied 
health in these units (Pok Oi Hospital, 2022; Tuen Mun Hospital, 2022). Indeed, psychiatric 
consultation-liaison services had been provided in both hospitals since the 1990s.  
Eligibility criteria 

 
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The inclusion criteria of the participants will be full-time registered nurses (general) or 
enrolled nurses (general) who care for adult patients in emergency departments or medical 
wards. There is no restriction on participants’ socio-demographic characteristics, such as gender 
and age. The exclusion criteria are a nurse who had a professional registration in the psychiatric 
stream, who does not understand Chinese and English, or who is unable to access or use the 
internet. 
Sample size 
According to the systematic review of the effectiveness of interventions in improving the 
mental health literacy of healthcare professionals in general hospitals, the effect size of an 
effective intervention ranged from Cohen’s d =0.75 to 1.32. However, the outcomes concern 
only a particular component of mental health literacy. Therefore, a more conservative effect size, 
Cohen’s d =0.5 was used for estimation of the sample size of the current study.  It is estimated 
using GPower that a sample size of 64 participants per group is adequate to detect an effect size 
of 0.5 on the primary outcomes at a post-intervention time point with 80% power at a 5% level 
of significance. Assuming an attrition rate of 15% (Catalogue of Bias Collaboration et al., 2017), 
this study will recruit 150 nurses (75 per group).  
Recruitment 

 
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The sampling method will be convenience sampling. Recruitment of participants will be 
solicited via a public announcement by the poster and electronic mail. The potential subjects will 
be screened based on the inclusion and exclusion criteria. An information sheet will be sent via 
electronic mail to the eligible nurses to provide information about the study including its 
purpose, data collection procedures, etc. In addition, voluntary participation and the right to 
withdraw from the study freely at any time without any consequences will also be reinforced. 
Moreover, all participants will be informed that a monetary incentive, a cash coupon of HKD 50, 
would be given upon completion of all the measurements to compensate for the time spent. 
Written informed consent will be obtained from the participants before the study's 
commencement.  
Study intervention 
The intervention group will receive an educational program consisting of six 30-minutes 
online educational sessions and followed by one 60-minutes face-to-face session (Refer to Table 
1.).  
In the first part, the six online educational sessions will be delivered on a private YouTube 
channel which consists of information about mental health literacy (knowledge about mental 
health, mental illnesses, and their management, attitude/ stigma related to mental illnesses, and 

 
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help-seeking efficacy), pre-post session questionnaires, and an online discussion forum. After 
educational materials were validated by two experienced psychiatrists and two advanced practice 
psychiatric nurses, educational videos will be uploaded to the private YouTube Channel and 
allowed participants to have six weeks of unrestricted access. Interactions will be facilitated 
through an online discussion forum and relevant articles, or web pages will be posted to facilitate 
further learning. The attendance of participants will be tracked and those who had trouble 
accessing the content will be contacted by the research team proactively. To reduce attrition, the 
research team will contact participants weekly,  and maintain ongoing communication through 
email. A friendly email reminder will be sent to participants who fail to complete access all the 
educational videos 5 days before the free access period ends. 80% attendance will be considered 
to be good compliance. After 6-weeks of free access to online education, participants will be 
arranged into small groups for a 60-minute face-to-face session. 
The second part is a face-to-face session which consists of problem-based learning and 
group sharing. In problem-based learning, participants will be divided into a group of 7-8 people. 
This session will be conducted by the associate consultant of the psychiatric consultation-liaison 
service and facilitated by the researcher. Participants were invited to read the vignettes of a 
patient with a mental illness in a general hospital. Two vignettes were provided, which are based 

 
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on the clinical scenarios which can happen in participants’ work and are meant to illustrate 
patients with physical-mental comorbidity in a general hospital who might benefit from 
psychiatric consultation-liaison service. Through group discussion, participants had to come up 
with the diagnosis of the case and offer an opinion on action that can be taken by general hospital 
nurses in helping patients with mental illnesses in general hospitals. In the group sharing, a 
summary of information about general hospital nurses’ mental health literacy obtained in the 
online education will be presented. Participants can identify the common mental health 
knowledge deficit, mental illness-related beliefs, and barriers in help-seeking among general 
hospital nurses who care for patients with mental illnesses. Participants are encouraged to share 
their personal experiences related to mental health literacy and to explore strategies for dealing 
with difficulties of caring for patients with mental illnesses in general hospitals, such as how to 
manage their own emotions when confronted with a challenging scenario. Furthermore, 
discussions will be guided on further strategies for promoting mental health literacy of healthcare 
professionals in general hospitals. For this session, the mode of delivery will be changed into 
zoom meetings according to the situation of disease outbreaks. The total duration of the 
educational program is 4 hours, and the intervention period will be seven weeks. 
The control group will not receive any educational intervention related to mental health 

 
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literacy.  
Data collection 
Before starting the educational program, the socio-demographic data of the participants 
including age, gender, marital status, education level, occupation, and working years will be 
collected. The information from participants will be collected through the self-reported form. 
The collection of these data can provide a more comprehensive picture of the background of the 
participants and allow initial equivalence among the study groups to be examined.  
In this study,  participants will be asked to complete a set of questionnaires including (1) 
Level of mental health literacy, (2) Perceived competency in caring for patients with mental 
illnesses, and (3) Level of work stress by online survey. All consenting participants will be 
assessed at baseline, immediate post-intervention, and one-month post-intervention. Participants 
from the control group will be assessed on the equivalent dates at the same time points. If there 
are missing responses to questionnaires completed by participants, the research assistant will 
follow up via phone or email up to three times to obtain the missing responses. 
To examine the interventional effect on the patient satisfaction with nursing care in general 
hospitals, patients being referred to psychiatric consultation-liaison service at the study sites will 

 
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be asked to complete the patient satisfaction survey at baseline (two weeks period before 
intervention), post-intervention (two weeks period immediate after intervention), and follow-up 
(two weeks period after one-month post-intervention).   
Measurements 
Primary outcome: Level of general hospital healthcare professionals’ mental health literacy 
The level of general hospital healthcare professionals’ mental health literacy will be 
evaluated using The Mental Health Literacy Scale developed by Connor & Casey (2015). This 
questionnaire comprised 35 items which consisted of the ability to recognize disorders (8 
questions), knowledge of where to seek information (4 questions), knowledge of risk factors and 
causes (2 questions), knowledge of self-treatment (2 questions), knowledge of professional help 
available (3 questions), attitudes that promote recognition or appropriate help-seeking behavior 
(16 questions) (O’Connor & Casey, 2015). Questions with a 4-point scale are rated “1” was very 
unlikely/unhelpful, “4” was very likely/helpful and for a 5-point scale that “1” strongly 
disagreed/definitely unwilling, “5” strongly agreed/definitely willing. The higher the total score 
indicates a higher level of mental health literacy. The scale demonstrated good internal and test-
retest reliability, and good validity. The Cronbach’s alpha of the 35-items scale was .873. Test-
retest reliability was r(69)=.797, p<.001. The scale was significantly positively correlated with 

 
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the General Help-seeking Questionnaire total scale of r(370)=.234, p<.001. 
Secondary outcome: perceived competency in caring for patients with mental illnesses 
The Behavioral Health Care Competency survey (Rutledge et al., 2013; Rutledge et al., 
2012) will be used to assess the perceived competency in caring for patients with mental 
illnesses. It consists of 23-items to assess the healthcare professionals’ perception of their 
competency in assessment, intervention, recognition of the need for referral, and dealing with 
resources issues (Rutledge et al., 2013; Rutledge et al., 2012). Questions with a 5-point Likert-
type scale with responses 1= “Strongly disagree” to 5=” Strongly agree” The higher the total 
score, the higher respondent’s perceived competency in caring for patients with mental illnesses. 
By using principal component analysis with varimax rotation, 23 items led to a factor structure 
with four components supported by Eigenvalues greater than one and visual inspection of the 
Scree plot. The Cronbach’s alpha for the subscale was assessment (.91), intervention (.90), 
recommendation (.78), and resources adequacy (.78). The scale demonstrated adequate construct 
validity and internal consistency.  
Secondary outcome: Level of work stress  
The Workplace Stress Scale developed by the Marlin Company and the American Institute 

 
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of Stress will be used to assess participants’ work stress levels. This scale consists of eight items 
that describe the perception of the respondent toward his or her work. Questions with a 5-point 
scale are rated “1’ was never, and “5” was very often. The higher the total score indicates a 
higher level of work stress. A total score of 15 or lower interpreted as stress is not much of an 
issue, whilst 31-40 was indicative of a potentially dangerous stress level that may need to seek 
professional assistance (Jadhav et al., 2018). The scale was validated by seeking opinions from a 
group of oncology nurses. The Cronbach’s alpha reliability coefficient was .80  (Soltan et al., 
2020) 
Secondary outcome: Patient satisfaction with nursing care  
Hospital Patient Satisfaction Survey (Huang & Yen, 2015) will be used to assess patient 
satisfaction with nursing care in general hospitals. There are eight questions on the scale to 
measure patient satisfaction with nursing care during the hospitalization with a 4-point Likert 
scale (from “0”=never to “4”=always). The scale had a good psychometric property with a 
content validity index of .97, item discrimination critical ratio of 28.61 to 50.25, and item 
correlations ranged from .68 to .84. The exploratory factor analysis with item factor loadings 
(factors of “professional knowledge and skill” and “environmental control”) ranged from .61 
to .84, explaining 71.40% of the total variance. The internal consistency was Cronbach’s 

 
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alpha= .97. (Huang & Yen, 2015).  
Data analysis 
Statistical analyses  
Statistical Package for Social Science will be used for data analysis will be employed for all 
statistical analyses.  
Descriptive statistics were used including means, standard deviations, medians, quartiles, 
and ranges for age, years of working years, and relative frequencies for gender, marital status, 
highest education, and occupation. Independent t, Mann-Whitney, chi-square, or Fisher's exact 
tests, as appropriate, to compare the socio-demographic characteristics between groups. For the 
outcomes, the generalized estimation equations (GEE) model will be used to examine the 
intervention effects. Each of the outcomes will be compared between groups with adjustment for 
potential confounding factors, for example, characteristics of participants shown statistically 
different between arms at baseline. An intention-to-treat, repeated measures analysis will be 
conducted to compare changes in the two groups over time. Three effects will be evaluated 
including the time effect, group effect, and time x group interaction effect. A 2-sided p value less 
than .05 will be considered statistically significance for all analyses. 

 
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Timetable of work 
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Development of the
educational
intervention
Ethical application
Participant
recruitment and
baseline data
Intervention
implementation
Immediate post-
intervention
measurement
One-month post-
intervention
measurement
Data analysis
2022
2023
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Figure 1. Timetable of work 
The study will be commenced in September 2022. The educational materials for the 
intervention will be prepared by an experienced psychiatric consultation-liaison nurse and 
validated by two psychiatrists and two advanced practice psychiatric nurses. The procedure may 
probably need two months to complete, suggesting that the learning material will be ready at end 
of June 2022. Ethical approval will be sought, and the recruitment is expected to start in 
September 2022. Baseline data collection will be started after consent is obtained. The 

 
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intervention is expected to start at end of February 2023. Post-intervention individual assessment 
will be done immediately after the program completion and one month after the program 
completion. It is expected that the finalization of data collection and analysis can be completed in 
November 2023. 
Ethical considerations 
This study will be conducted in compliance with the International Conference on 
Harmonization of Good Clinical Practice (ICH-GCP) and the Declaration of Helsinki. The 
intervention and data collection in this study are safe, and no known risk is envisaged concerning 
the participants’ physical and/or mental health.  Ethical approval to conduct the study will be 
obtained from the Clinical and Research Ethics Committee of the target hospitals (New 
Territories West Cluster Research Ethics Committee) and the Joint Chinese University of Hong 
Kong- New Territories East Cluster Clinical Research Ethics Committee. Before the study 
commences, written consent will be sought from eligible and interested participants. The 
information including the purpose of the study, method of data collection procedures, and their 
response remains anonymous and confidential and will be provided to the participants. For the 
data collection from patients in the study sites, the investigator will provide potential subjects 
with an outline of the survey and what participation entails. Informed consent will be sought, and 

 
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26 
 
subjects can contact principal investigators for any inquiries. All participants should voluntarily 
participate in the study and can be free to withdraw from the study or terminate participation at 
any time without any consequences.  
In the data collection process, all the data will be coded and encrypted. Each returned 
questionnaire will be assigned with a study code. Anonymity and confidentiality will be assured. 
The data collection will follow The Personal Data (Privacy) Ordinance in Hong Kong. Any 
personally identifiable information or any information obtained in connection with this study will 
remain confidential and the identities of participants will at no time be revealed in any report of 
this study. The research team will use a made-up name for participants in any writing or 
presentation. Only the research team will know about participants’ specific answers.  
The research data will be kept in locked cabinets in a secured office and the electronic data 
will be kept in a secured computer with restricted access. Personal data will not be stored on a 
USB device. Personal data including name, HKID, address, and any other personally identifiable 
information, would not be collected for this study. The document of an electronic file containing 
the linkage information between the study code and the identity of the participant would not 
contain any other information and would be kept separate from the study data files or 
questionnaires with the same stringent security as the medical record according to the hospital 

 
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policies. The principal investigator will be responsible for safekeeping on the personal data 
during and after the study. After the study, the data will be kept for 3 years (The Office of the 
Federal Register of the National Archives and Records Administration & The U.S. Government 
Publishing Office, 2018). Then, all the data will be deleted, and the documents will be shredded. 
Significance of the study 
The implementation of the educational program is expected to improve general hospital 
nurses’ mental health literacy, perceived competency in caring for patients with mental illnesses, 
and work stress. This study will provide evidence-based data regarding the application of the 
educational program in healthcare organizations to improve general hospital nurses’ level of 
mental health-related knowledge, attitudes, help-seeking efficacy, their perceived competency in 
caring for patients with mental illnesses, and their work stress. This is especially important for 
general hospital nurses who experiencing challenges in caring for patients with physical-mental 
comorbidity in general hospitals. The findings of this study are expected to provide new 
knowledge that may contribute to the future development of an in-service training program 
aimed at improving clinical practices for caring for patients with physical-mental comorbidity in 
general hospitals. 
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