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Clinical Education In psychiatric mental health nursing: Overcoming current challenges
Clinical Education In psychiatric mental health nursing: Overcoming current challenges Heeseung Choi, Boyoung Hwang, Sungjae Kim, Heesung Ko, Sumi Kim, Chanhee Kim PII: DOI: Reference:
S0260-6917(16)00048-4 doi: 10.1016/j.nedt.2016.01.021 YNEDT 3188
To appear in:
Nurse Education Today
Accepted date:
25 January 2016
Please cite this article as: Choi, Heeseung, Hwang, Boyoung, Kim, Sungjae, Ko, Heesung, Kim, Sumi, Kim, Chanhee, Clinical Education In psychiatric mental health nursing: Overcoming current challenges, Nurse Education Today (2016), doi: 10.1016/j.nedt.2016.01.021
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ACCEPTED MANUSCRIPT Abstract Background: In response to current challenges in psychiatric mental health nursing
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education, nursing schools have implemented new strategies in teaching undergraduate
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nursing students.
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Objectives: The objectives of the study were to evaluate learning outcomes of a mental health nursing clinical practicum and to explore students’ perceptions of the clinical practicum. Design: This was a mixed-method study. Sixty-three undergraduate nursing students, who
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were undertaking their first mental health clinical practicum, completed a set of structured
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questionnaires and answered open-ended questions about the clinical practicum. Methods: Answers to open-ended questions were analyzed qualitatively, and learning outcomes (i.e., empathy, mental illness prejudice, simulation-related efficacy, and satisfaction)
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were measured at three time points: pre-clinical, post-simulation, and post-clinical. Results: Students reported improvement in empathy and simulation-related self-efficacy after
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the clinical practicum, but no change was found in mental illness prejudice. Students’ expectations for and evaluation of the clinical practicum are summarized.
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Conclusions: The observed improvement in learning outcomes of the clinical practicum may be attributed to the unique contribution of each component of the clinical practicum and the synergic effect of these diverse components. To manage emerging challenges in clinical settings and nursing education, it is critical to develop systematic and comprehensive mental health nursing clinical practicums for undergraduate nursing students. Keywords: mental health nursing clinical practicum, empathy, mental illness prejudice, simulation
ACCEPTED MANUSCRIPT Introduction Psychiatric mental health nursing clinical practicums are designed to provide nursing
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students with the opportunity to integrate necessary knowledge, skills, and attitudes toward
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the mentally ill during practice. Students engage in the psychiatric mental health nursing
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process through therapeutic relationships and communication with mentally ill patients during their clinical practicums (Perese, 1996). In addition, students confirm their understanding of mental illness by interacting with actual patients. In particular, empathy toward highly
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distressed patients is critically important in mental health nursing practicums, because an empathetic attitude is an essential component of the nurse-patient relationship (Ketola and
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Stein, 2013). Empathy is defined as an ability to understand patients’ feelings and convey their recognition accurately (Reynolds, 2000). Empathy allows nursing students to build trust,
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and mentally ill patients who recognize nursing students as empathetic feel accepted and respected (Riley, 2012). Therefore, mental health clinical practicums should be designed to
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enhance students’ empathetic abilities through various methods of education. One of the hindering factors to the development of empathy is prejudice toward
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mental illness. Prejudice is based on negative perceptions, such as the common beliefs that mentally ill persons are dangerous, unpredictable, or impossible to treat, and hamper the therapeutic relationship between nursing students and patients (Webster, 2010). Previous studies revealed that most nursing students showed a considerable level of anxiety and fear associated with prejudice related to mental illness prior to mental health clinical practicums (Hyun and Seo, 2000; Lehr and Kaplan, 2013; Perese, 1996). Quality of nursing care for patients is affected by mental illness prejudice among nurses (Noh, 2000). Hence, prejudice associated with mental illness is a critical component that must be addressed in mental health nursing clinical practicums (Chadwick and Porter, 2014; Schafer et al., 2011).
ACCEPTED MANUSCRIPT The number of nursing schools in Korea has greatly increased from 133 in 2008 to 201 in 2014 (Korean Nurses Association, 2015). With the recent rapid increase in the number
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of nursing schools, there have been significant concerns regarding the quality of nursing
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education and the lack of consensus on standardized curriculums for mental health nursing
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practicums. The increased number of nursing schools also created a shortage of settings for mental health clinical practicums. Moreover, with the increased awareness of patients’ rights and safety, opportunities for students to engage in therapeutic activities and one-on-one
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interaction with patients have been limited (Brown, 2008; Waldner and Olson, 2007).
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To address these challenges in clinical settings, simulation-based education has been applied to nursing education. Clinical simulations using standardized patients are intended to help students apply knowledge in various clinical situations and provide opportunities to
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assess and intervene mental health problems. In clinical psychiatric nursing training, simulation offers opportunities to communicate with standardized patients in a safer setting
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(Choi, 2013; Robinson-Smith et al., 2009). Moreover, simulation is helpful in reducing student anxiety when entering psychiatric units for clinical practicums. Undergraduate
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students may have their first interactions with psychiatric patients during their clinical practicums; therefore, they may not know what to expect from the patients or themselves in practice. Self-confidence and satisfaction with learning are high after simulation-based education among nursing students, because simulation provides learning opportunities in a non-threatening environment (Brown, 2008; Choi, 2013; Park and Kweon, 2012; RobinsonSmith et al., 2009). Therefore, there is an urgent need to develop and apply a mental health clinical curriculum that meets educational goals while overcoming the current challenges faced by nursing schools. The aims of this study were twofold: 1) to evaluate learning outcomes of clinical psychiatric nursing training, such as development of empathy, reduction of mental
ACCEPTED MANUSCRIPT illness prejudice, simulation-related efficacy, and satisfaction with simulation; 2) to explore students’ perceptions of clinical practicums before and after completion of a mental health
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nursing clinical practicum.
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Methods
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Clinical Course Content
The 5-week psychiatric mental health nursing clinical practicum (clinical practicum) consisted of four main components: clinical placements, psychiatric nursing simulation,
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clinical group seminars, and assignments. Psychiatric mental health nursing faculty, clinical
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instructors, and preceptors in each hospital unit (unit-based clinical education facilitators) participated in the clinical education program. The flow and components of the clinical
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Clinical placements
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practicum are summarized below.
Clinical placements took place at both psychiatric hospitals and community mental
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health centers. For diverse clinical experiences, each student spent a total of four weeks in two of the psychiatric hospital units, including adult open and closed units, a child and
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adolescent unit, and a day-hospital unit. Students also spent the last week of the clinical practicum at one of the community mental health centers. During the clinical practicum, students were required to attend meetings and therapy groups in the assigned units and directly and indirectly participate in patient care. Simulation sessions We provided two levels of psychiatric nursing simulation sessions using standardized patients: a 10-minute one-on-one communication simulation and a 20-minute complex case simulation. The 10-minute one-on-one communication simulation was designed to provide students opportunities to practice therapeutic communication skills for clients experiencing common psychiatric symptoms, such as anxiety, depression, aggression, hallucinations, and
ACCEPTED MANUSCRIPT delusions. The 20-minute complex case simulation dealt with a case of an alcoholic patient experiencing withdrawal symptoms and focused on communication with a family member
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and health care team members as well as critical thinking. Both clinical simulation sessions
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consisted of three components: orientation, clinical simulation, and debriefing. Peer-
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observation was another critical component facilitating vicarious learning among students. For the one-on-one communication simulation, each student participated in two of the four simulation cases and observed peers performing the other two simulation cases through a
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Real-time Observation Monitor (while waiting to participate). During the debriefing session,
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students had a chance to share thoughts and feelings they had during the simulation, and discuss areas for improvement. A synopsis of the scenarios and flow of the simulation
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Clinical group seminars
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sessions are summarized in Table 1.
During the 5-week clinical practicum, students attended two clinical group seminars: a
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self-understanding activity and case conference. The self-understanding activity was intended to help students understand themselves by looking back on their own childhood, past
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experiences, and relationships with significant others. For the case conference seminar, each student was prepared to discuss one clinical case that consisted of the complete assessment of a patient and prioritized nursing diagnoses with implemented nursing interventions. Students also evaluated patient outcomes of nursing interventions and shared lessons learned. Assignments During the 5-week clinical practicum, students were required to submit eight clinical reports that included critical reflective journaling. In addition, they completed a group activity report, a case study, and a report on the community mental health center. For the community mental health center report, students presented the characteristics and roles of each community center where they were placed.
ACCEPTED MANUSCRIPT Course Evaluation Design and sample
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This was a mixed-method study. To evaluate learning outcomes of the mental health
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nursing clinical practicum, we conducted a pre- and post-clinical survey with 63
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undergraduate nursing students who were undertaking their first mental health clinical practicum. Changes in empathy, mental illness prejudice, simulation-related self-efficacy, and satisfaction before and after the clinical practicum were measured using a set of
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questionnaires. Students were also asked to answer demographic questions and open-ended
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questions assessing their expectations for and satisfaction with clinical practicum. In addition, subgroup analyses were conducted by comparing data from 22 students who took the mental health clinical practicum in the beginning of the semester (Group 1) with those from 22
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students who answered the questionnaires before and after a clinical practicum for another course, which provided limited contact with patients and took place prior to the mental health
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clinical practicum (Group 2; comparison group). The data collection schedule for the main and subgroup analyses is depicted in Table 2.
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Procedure
Questionnaires were completed on the first and last day of the mental health clinical practicum, as well as immediately after the one-on-one communication simulation, which took place during the second week (Table 2). For the subgroup analyses, students in the comparison group (Group 2) were asked to complete an additional set of questionnaires in the beginning of the semester. Data were collected from March 2015 through June 2015. The study was reviewed and approved by the institutional review board of the university, and informed consent was obtained from each participant. To ensure voluntary participation, a research assistant, who was not involved in the course, obtained consent, and
ACCEPTED MANUSCRIPT distributed and collected the completed questionnaires. Study identification numbers were managed by the research assistant and were not shared with the educators.
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Questions about the mental health clinical practicum.
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Measurements
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Using the open-ended pre- and post-clinical questions developed by Ketola and Stein (2013), we assessed students’ anticipation regarding individuals with mental illness, opinions about how the clinical experience would affect them as nurses, and reflections on their
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personal development prior to and after the clinical practicum.
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Students were also asked to rate their expectations for and satisfaction with the clinical practicum on a scale from 1 (no expectations/very unsatisfied) to 10 (high expectations/very satisfied) before and after the clinical practicum. We also asked students whether they
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considered mental health nursing to be a career option. At the end of the clinical practicum, students were asked to rate their satisfaction with each component (i.e., psychiatric hospital
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clinical placement, community mental health center clinical placement, simulation, and group seminars) on a scale from 1 (very unsatisfied) to 5 (very satisfied).
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Empathy.
To measure empathetic capacity, we used the Empathy Construct Rating Scale developed by Monica (1981) and translated into Korean by Kim (1988). This instrument consists of 52 items, each rated on a 6-point Likert scale. The total score ranges between 52 and 312, with higher scores indicating better empathetic capacity. The Cronbach’s α for the Empathy Construct Rating Scale was .95 in this study. Mental illness prejudice. We used the Social Stigma Scale of Mental Illness Patients developed by Kim and Seo (2004) to measure prejudice toward mentally ill persons. This instrument contains 25 items grouped into four factors: dangerousness (8 items), incompetence (4 items), impossibility to
ACCEPTED MANUSCRIPT recover (8 items), and distinguishability (5 items). Three factors (dangerousness, impossibility to recover, and distinguishability) were used in our study. Each item is rated on a 4-point
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Likert scale with a total score ranging between 21 and 84. Higher scores indicate greater
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mental illness prejudice. Each subscale of the Social Stigma Scale of Mental Illness Patients
(impossibility to recover) to 0.82 (dangerousness).
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showed acceptable reliability in our sample, with Cronbach’s αs ranging from 0.769
Simulation-related self-efficacy and satisfaction.
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Simulation related self-efficacy was measured with the Post-Training Self-Efficacy
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scale developed by Ayres (2005) and translated into Korean by Park and Kwon (2012). Posttraining self-efficacy refers to belief in the ability to utilize new learning after professional education. The scale consists of 10 items on a 7-point Likert scale. The total score ranges
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between 10 and 70, with higher scores representing better post-training self-efficacy. Cronbach’s α for post-training self-efficacy was .93 in this study.
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We used the Student Satisfaction and Self-Confidence in Learning scale developed by Jeffries (2012) and translated into Korean by Park and Kwon (2012), to evaluate satisfaction
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with and self-confidence after simulation learning. Each item is rated on a 7-point Likert scale with a total score ranging between 11 and 77. Higher scores indicate higher satisfaction with education. The instrument was modified in our study to measure simulation-related satisfaction, and showed good reliability with Cronbach’s α of .90. Analysis Quantitative data were analyzed with IBM SPSS 22 (IBM, Armonk, NY 2013). Baseline characteristics of the study sample and student ratings of the clinical practicum were summarized using descriptive statistics (i.e., means, standard deviations [SD], frequencies, and ranges). Using paired t-tests, pre- and post-clinical scores on empathy and mental illness prejudice were compared in the entire sample. Changes in simulation-related self-efficacy
ACCEPTED MANUSCRIPT measured at pre-clinical, post-simulation (during the second week of clinical practicum), and post-clinical were examined using one-way repeated measures analysis of variance. A
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Bonferroni correction was used in post-hoc pairwise comparisons. We then performed
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subgroup analyses to examine changes in scores on empathy, mental illness prejudice, and
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self-efficacy before and after the clinical practicum between students who completed the mental health clinical practicum (n = 22) and those who completed clinical practicums for other courses (comparison group; n = 22) during the same period. In these subgroup analyses
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using repeated measures analysis of variance, the models included a fixed time factor (pre-
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and post-clinical), a grouping factor (mental health clinical practicum vs. nursing management clinical practicum), and a two-way interaction term between time and grouping factor. The statistical significance level was set at p < .05.
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Students’ answers to the open-ended pre- and post-clinical questions were analyzed qualitatively. After intensive review, we grouped answers with similar meanings and
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confirmed frequencies.
Results
Practicum
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Characteristics of Study Participants and Questions about the Mental Health Clinical
Among the 63 students who enrolled in the course, 52 (83%) were female. Students ranged in age from 21 to 30 years (mean 22.20 years, SD 1.88). Prior to the mental health clinical practicum, the mean score of expectations for the practicum was 7.12 (SD 1.67, median 7.00), and the average post-clinical satisfaction score was 7.82 (SD 1.91, median 8.00), which was significantly higher than the pre-clinical expectation score (t = -2.65, df = 59, p = .010). Before the clinical practicum, 32 students (51%) considered mental health nursing as a career option. Of these, four students changed their mind after the clinical practicum. Among the 31 students who did not consider mental
ACCEPTED MANUSCRIPT health nursing as a career option before the clinical practicum, 12 did so after the clinical practicum.
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Among the four clinical education components, students reported the highest
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satisfaction with the simulation (mean 4.46, SD 0.63), followed by the psychiatric hospital
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clinical placement (mean 4.29, SD 0.71) and group seminars (mean 4.11, SD 0.75). The lowest satisfaction was reported for the community mental health center clinical placement (mean 3.42, SD 1.00).
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Changes in Empathy, Mental Illness Prejudice, and Simulation-Related Self-Efficacy
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and Satisfaction
Table 3 shows mean scores on empathy, mental illness prejudice, simulation-related self-efficacy, and satisfaction before and after the clinical practicum among study participants.
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The level of empathy significantly improved from 241.84 (SD 22.77) before the clinical practicum to 255.46 (SD 24.03) after the clinical practicum (t = -6.48, df = 62, p < .001).
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There was no significant change in scores of mental illness prejudice pre- and post-clinical [mean pre-clinical score: 42.13 (SD 6.60); mean post-clinical score: 40.97 (SD 7.91); t =
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1.401, df = 62, p = .166]. Among the three subscale scores, the dangerousness score significantly decreased (representing improvement in prejudice) from 20.13 (SD 3.25) before the practicum to 17.76 (SD 3.93) after the practicum (t = 6.25, df = 62, p < .001); however, the impossibility to recover score significantly worsened from 12.94 (SD 2.91) to 13.95 (SD 3.33) (t = -2.57, df = 62, p = .013). The distinguishability score did not show a significant change after the clinical practicum (t = -0.57, df = 62, p = .57). In the repeated measures analysis of variance, we found a significant increase in levels of self-efficacy measured at preclinical, post-simulation, and post-clinical [F (2, 124) = 5.06, p = .008]. In the post-hoc pairwise comparisons, we found no significant changes from pre-clinical to post-simulation and from post-simulation to post-clinical (p’s > .05); however, the change from pre-clinical to
ACCEPTED MANUSCRIPT post-clinical was significant (p = .005). The mean score on simulation satisfaction was 64.84 (SD 6.23) immediately after the simulation and slightly increased to 66.46 (SD 7.62) after the
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clinical practicum. However, this increase was not statistically significant (t = -1.79, df = 62,
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p = .078).
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Subgroup Analyses
Table 4 summarizes the results from subgroup analyses comparing changes in scores on empathy, mental illness prejudice, and self-efficacy before and after the clinical practicum
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between students who completed the mental health clinical practicum and those in the
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comparison group. As shown in Figure 1, students who completed the mental health clinical practicum had a larger improvement in empathy scores than those in the comparison group [F(1, 42) = 6.20, p = .017]. However, there were no significant differences in changes in
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prejudice scores [F(1, 42) = 0.82, p = .37] or simulation-related self-efficacy scores [F(1, 42) = 0.49, p = .49] before and after the clinical practicum between the two groups of students.
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Among the subscale scores for mental illness prejudice, the interaction between time and grouping factor was significant for dangerousness [F(1, 42) = 10.09, p = .003], but not for
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impossibility to recover or distinguishability [F(1, 42) = 2.98, p = .092; F(1, 42) = 0.04, p = .85, respectively]. Students who completed the mental health clinical practicum showed a significant improvement in the dangerousness subscale (p = .015), while students in the comparison group showed no significant change (p = .058) (Figure 2). Qualitative Findings Quotes from the qualitative data supported the findings of the quantitative analysis that the clinical practicum enhanced empathy and simulation-related efficacy. A student (Student 16) said, “It [the clinical practicum] gave me a chance to put myself in other’s shoes and I became attentive to others’ needs.”
ACCEPTED MANUSCRIPT Regarding the clinical simulation using standardized patients with various symptoms, another student (Student 49) said,
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“Because of this opportunity to interact with psychiatric patients, I will have fewer
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difficulties in interacting with psychiatric patients in the clinical rotation.” Another
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student (Student 30) said,
“In the clinical situation, I was just an observer. But, in the simulation, I could react quickly to the unexpected situation and actively participate.”
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Even though changes in the level of mental illness prejudice were not statistically
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significant after the clinical practicum, these quotes demonstrate changes in students’ perceptions toward mental illness and people with mental illness. A student (Student 43) said, “They [psychiatric patients] are not bugaboos but people like us. If they control their
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acting out, they can socialize with us.” Moreover, another student (Student 11) said, “I became interested in people with mental illness. My prejudice decreased with the
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clinical practicum, and it lessened my resistance to the mentally ill. Not all psychiatric patients are aggressive.”
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Additional qualitative findings of student expectations for and satisfaction with the clinical practicum are summarized in Table 5. Discussion
This paper introduced an example of a curriculum for an undergraduate mental health nursing clinical practicum. We also evaluated learning outcomes of the clinical practicum and explored students’ perceptions of the clinical practicum. In our study, the level of empathy among students significantly improved after the clinical practicum. Improvement in empathy was also significant in a subgroup analysis comparing two groups: students who completed the mental health clinical practicum and those in another course. Brunero et al. (2010) showed that the level of empathy or empathy skills among
ACCEPTED MANUSCRIPT nursing students significantly improved after a skills-based course, undergraduate courses, an art program, and special education/training programs. Therefore, in our study, diverse
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teaching strategies, including exposure to diverse clinical settings, experiential learning (i.e., a
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psychiatric nursing simulation using standardized patients) and activities enhancing self-
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reflection such as a self-understanding activity and critical reflective journaling, may have contributed to the increase in empathy among nursing students. Scholars (Brunero et al., 2010; Ward et al., 2012) have recommended that simulations or role-playing with standardized
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included in empathy education in nursing.
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patients and learning activities enhancing self-awareness and self-reflection should be
Empathy is a critical component in the development of the therapeutic nurse-patient relationship and is beneficial to both patients and nurses; therefore, improving empathy
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among nursing students is of importance. In particular, the cognitive aspect of empathy (i.e., perspective taking) is positively associated with work engagement and job satisfaction, and
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negatively with turnover intention among nurses (Pohl et al., 2014). With technology advances and the increasing importance of cost-effectiveness in health care, the focus of
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nursing has shifted from providing person-centered care to mastering technical skills and advanced knowledge (Heller et al., 2000; Huston, 2013). Furthermore, changes in health care environments and nursing education have affected the development of empathy. Ward et al. (2012) reported a counterintuitive decline in the level of empathy among undergraduate nursing students, particularly those with more clinical encounters with patients. Thus, nursing education that enhances empathy is needed. Another expected learning outcome of the present study was decreased mental illness prejudice among nursing students. In our study, the level of mental illness prejudice did not change among nursing students after the mental health clinical practicum. In the analysis of prejudice subscales, while the scores on dangerousness improved, scores on impossibility to
ACCEPTED MANUSCRIPT recover worsened. In other words, students perceived individuals with mental illness as less dangerous after the clinical practicum, whereas they became less hopeful for recovery from
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mental illness after the clinical practicum. These findings are consistent with those of
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previous studies (Bae, 2002; Yang and Yu, 2001). Students’ answers to open-ended questions
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reflected changes in their perceptions toward the dangerousness of people with mental illness, reporting that they learned not all psychiatric patients are aggressive and psychiatric patients could socialize with others.
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The finding that students became less hopeful for recovery from mental illness after
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the clinical practicum is not surprising. In Hugo’s study (2001), mental health professionals were more pessimistic about recovery from mental illness than the general public. He reported that health care professionals’ negative views are possibly based on a more realistic
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assessment and are associated with their own experiences with mental health problems. In his study, all mental health professionals believed that persons with mental illness would recover
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partially or fully if they received professional help. Overall, no significant change in mental illness prejudice after the clinical practicum
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was noted in our study. The 5-week clinical practicum might not have been enough to cause changes in mental illness prejudice deeply rooted in social values (Pescosolido, 2013). Corbiere et al. (2012) claimed that reducing the prejudice of mental illness requires diverse strategies, such as public education/teaching, normalizing, working on recovery by supporting and encouraging the mentally ill, and contact with people with mental illness. Thus, it is believed that diverse approaches at different levels beyond the clinical practicum are needed to fight the prejudice of mental illness. In our study, students exhibited significantly improved simulation-related self-efficacy after the practicum. In addition, regarding satisfaction with the clinical practicum, students rated the clinical simulation highest among all components. Students reported that the
ACCEPTED MANUSCRIPT simulation enabled them to practice therapeutic communication skills in a safe environment and thus built up their confidence in interacting with patients exhibiting psychiatric symptoms.
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Previously, Kameg et al. (2010) reported that a clinical simulation was effective in improving
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student self-efficacy regarding communication skills.
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Students also reported that the various cases and debriefing sessions of the clinical simulation allowed them to explore personal behaviors, beliefs, and attitudes toward psychiatric patients and to identify their own strengths and weaknesses as a nurse. This
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finding is consistent with Brown (2008) who found that a clinical simulation helped students
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to develop an in-depth understanding of themselves. Thus, self-reflective experiences might contribute to increased empathy among nursing students. Overall, the clinical practicum had positive effects on undergraduate nursing students’
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experiences with mental health nursing education and produced desirable learning outcomes. The findings of the present study inform future directions for mental health nursing
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practicums. Suggestions are as follow: Develop agreed-upon core components of clinical practicums and teaching strategies
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for accomplishing core competencies of mental health nursing education. While core competencies of nursing education have been developed, there is no consensus on the core components of mental health nursing clinical practicums. 2.
Continue to incorporate clinical simulations into mental health nursing practicums. Clinical simulations appear to be effective in improving self-efficacy and generating high student satisfaction. For future clinical practicums, it is important to develop structured simulation scenarios with diverse cases and scenarios that require different levels of clinical competencies.
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Develop standardized assessment tools to assess the quality of mental health nursing practicums and to evaluate learning outcomes. Development of systematic and reliable
ACCEPTED MANUSCRIPT assessment tools is essential for continuous quality improvement of mental health clinical practicums.
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Conclusion
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The findings of this study showed evidence that a 5-week mental health nursing
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clinical practicum improved empathy, simulation-related self-efficacy, and one aspect of mental illness prejudice among nursing students. Overall, students were satisfied with the clinical practicum experience, particularly the clinical simulation using standardized patients.
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We believe that the observed improvement in learning outcomes can be attributed to a unique
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contribution of each component of the clinical practicum and the synergic effect of those diverse components. Therefore, to manage emerging challenges in clinical settings and nursing education, it is critical to develop systematic and comprehensive mental health
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nursing clinical practicums for undergraduate nursing students.
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Aldershot, UK.
Riley, J.B., 2012. Communication in nursing, 7th ed. Elsevier Health Sciences, St. Louis,
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Robinson-Smith, G., Bradley, P.K., Meakim, C., 2009. Evaluating the use of standardized
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patients in undergraduate psychiatric nursing experiences. Clinical Simulation in Nursing 5(6), e203-e211.
Schafer, T., Wood, S., Williams, R., 2011. A survey into student nurses' attitudes towards mental illness: Implications for nurse training. Nurse Education Today 31(4), 328-332. doi:10.1016/j.nedt.2010.06.010 Waldner, M.H., Olson, J.K., 2007. Taking the patient to the classroom: Applying theoretical frameworks to simulation in nursing education. International Journal of Nursing Education Scholarship 4, Article18. doi:10.2202/1548-923x.1317
ACCEPTED MANUSCRIPT Ward, J., Cody, J., Schaal, M., Hojat, M., 2012. The empathy enigma: An empirical study of decline in empathy among undergraduate nursing students. Journal of Professional
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Nursing 28(1), 34-40. doi:10.1016/j.profnurs.2011.10.007
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Webster, D., 2010. Promoting empathy through a creative reflective teaching strategy: A
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mixed-method study. Journal of Nursing Education 49(2), 87-94.
Yang, S., Yu, S.J., 2001. The stigma toward the mental illness and mentally ill patients among nursing students between before and after learning psychiatric mental health nursing.
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Journal of Korean Academy Psychiatric Mental Health Nursing 10(3), 421-435.
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Table 1. Synopsis of simulation scenarios and flow of the simulation sessions Synopsis of Simulation Scenarios
Communication
A 30-year-old male patient with schizophrenia refuses to take
Scenario 1:
medication due to auditory hallucinations and persecutory
Schizophrenia
delusions.
Communication
A 53-year-old female patient with generalized anxiety disorder
Scenario 2: Generalized
walks back and forth and exhibits excessive anxiety, worry,
anxiety disorder
and restlessness.
Communication
A 27-year-old female patient with borderline personality
ACCEPTED MANUSCRIPT disorder aggressively insists on keeping a craft knife in her
personality disorder
room to work on origami as she wishes.
Communication
A 43-year-old female, whose son drowned during a family
Scenario 4: Major
camping trip six months ago, exhibits depressed mood, loss of
depressive disorder
energy, excessive guilt, insomnia, and suicidal ideation.
Complex case scenario
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Scenario 3: Borderline
A 53-year-old male patient is admitted to the emergency room with multiple abrasions and possible fractures after falling
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down the stairs. He has been drinking a bottle of vodka almost
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every day for more than 10 years and started drinking heavily after retiring from work about two and a half years ago. While
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waiting to be seen by an orthopedic surgeon, he begins to
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experience acute alcohol withdrawal symptoms and delirium tremens. As a primary nurse, the student is expected to provide
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care for the patient and communicate with his wife who denies her husband’s alcohol problem and refuses his admission to the
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psychiatric unit. Flow of Simulation Sessions
Communication Communication Communication Communication Scenario 1
Scenario 2
Scenario 3
Scenario 4
Group 1
Participation in the simulation
Real-time observation
Group 2
Real-time observation
Participation in the simulation
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Table 2. Clinical practicum and questionnaire completion schedule
1
Group 1
2
Weeks 3
Weeks 4
5
6
7
8
Weeks 9
10
Psychiatric mental health clinical practicum
Questionnaire ↑a,d Group 2
↑b
Control group
↑c,e Psychiatric mental health clinical practicum
Questionnaire ↑d
↑a,e
↑b
↑c
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12 12
13
14
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Group 3
clinical practicum ↑a
↑b
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Questionnaire
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↑ indicates questionnaire completion. a,b,c
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Pre-clinical, post-simulation, and post-clinical measurements for the main analyses.
d,e
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Pre- and post-clinical measurements for the subgroup analyses.
↑c
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Post-simulation
Post-clinical
p-value
241.84 ± 22.77
Not measured
255.46 ± 24.03
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< .001
42.13 ± 6.60
Not measured
40.97 ± 7.91
.166
Self-efficacy
57.51 ± 5.46
59.54 ± 8.18
60.38 ± 6.31
.008
Satisfaction
Not measured
66.46 ± 7.62
.078
Empathy
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Mental illness
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Pre-clinical
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Table 3. Mean empathy, mental illness prejudice, simulation-related self-efficacy, and satisfaction scores at pre-clinical, post-simulation, and post-clinical in the study sample (n = 63)
a
prejudice
64.84 ± 6.23
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Higher scores represent worse mental illness prejudice.
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a
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P-values are for paired t-tests (empathy, prejudice, and satisfaction) or for one-way repeated measures analysis of variance (self-efficacy).
ACCEPTED MANUSCRIPT Table 4. Comparisons of empathy, mental illness prejudice, and simulation-related selfefficacy scores before and after the clinical practicum between students who completed the
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psychiatric mental health nursing clinical practicum and those in the comparison group Psychiatric mental health nursing
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Comparison group clinical practicum
p-
Pre-clinical
Post-clinical
Pre-clinical
Post-clinical
245.23 ± 21.51
257.55 ± 20.26
241.23 ± 20.42
241.27 ± 21.11
.017
39.95 ± 4.43
40.59 ± 6.91
42.50 ± 8.58
44.59 ± 7.24
.371
58.14 ± 6.80
61.59 ± 5.10
55.50 ± 8.12
57.41 ± 5.33
.486
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Empathy
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Mental illness
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prejudicea Self-efficacy
P-values are for repeated measures analysis of variance.
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Higher scores represent worse mental illness prejudice.
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a
value
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(n = 22)
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Table 5. Summary of answers to open-ended questions about the psychiatric mental health nursing clinical practicum
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Expectations before the clinical practicum
Observation of mental health nursing practice; development of rapport,
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The clinical practicum will provide me with the following opportunities:
communication with patients, keeping the therapeutic milieu for patients (24.2%) Observation of and understanding psychiatric symptoms (21.9%)
Development of fundamental nursing competencies; therapeutic communication skills,
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nursing roles, managing patients with emotional problems (19.6%) Exploration of career options (9.4%)
Improvement of communication skills (7.8%)
A unique experience to satisfy my curiosity (4.7%)
Self-reflection (3.9%)
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Evaluation of the clinical practicum
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The clinical practicum provided me with the following opportunities: Development of competency in using the self as a therapeutic tool for patients; communication with patients, sharing their emotions, practicing direct patient care (16.4%)
Practice of therapeutic communication skills (14.1%)
Change in my perspectives on nursing; consideration of the emotional aspects of physically ill patients and the importance of treating patients as human beings (14.1%)
Self-reflection (11.7%)
Understanding psychiatric symptoms and the mental illness process (7.1%)
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Reduction of prejudice regarding mental illness (7.1%)
Observation of direct nursing care provided by mental health nurses (3.9%)
Improvement in understanding of human beings (3.9%)
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Fig. 1 Pre- and post-clinical empathy scores in students who completed the psychiatric mental health clinical practicum and those in the comparison group
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[Attached as a separate file]
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Fig. 2 Pre- and post-clinical dangerousness subscale scores in students who completed the psychiatric mental health clinical practicum and those in the comparison group (higher scores represent worse mental illness prejudice)
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION CLINICAL EDUCATION IN PSYCHIATRIC MENTAL HEALTH NURSING:
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OVERCOMING CURRENT CHALLENGES
Heeseung Choi, PhD, MPH, RN1, Boyoung Hwang, PhD, RN1*, Sungjae Kim, PhD, RN1,
College of Nursing & The Research Institute of Nursing Science, Seoul National University,
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1
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Heesung Ko, PhD(c), MSN, RN2, Sumi Kim, PhD(c), MA, RN2, Chanhee Kim, MSc, RN2
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Seoul, Korea; 2College of Nursing, Seoul National University, Seoul, Korea
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Source of funding: None.
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Conflicts of interest: None.
*Address for Correspondence:
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Boyoung Hwang, PhD, RN, College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, Korea 110-799; E-mail: [email protected]
Word count: 5,000 words (including references and abstract)
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Highlights: We evaluated learning outcomes of a mental health nursing clinical practicum. Sixty-three students completed a 5-week mental health nursing clinical practicum.
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The clinical practicum improved empathy and simulation-related self-efficacy. No change was found in mental illness prejudice after the clinical practicum.
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The present study informs future directions for mental health nursing practicums.
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S0260-6917(16)00048-4 doi: 10.1016/j.nedt.2016.01.021 YNEDT 3188
To appear in:
Nurse Education Today
Accepted date:
25 January 2016
Please cite this article as: Choi, Heeseung, Hwang, Boyoung, Kim, Sungjae, Ko, Heesung, Kim, Sumi, Kim, Chanhee, Clinical Education In psychiatric mental health nursing: Overcoming current challenges, Nurse Education Today (2016), doi: 10.1016/j.nedt.2016.01.021
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Abstract Background: In response to current challenges in psychiatric mental health nursing
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education, nursing schools have implemented new strategies in teaching undergraduate
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nursing students.
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Objectives: The objectives of the study were to evaluate learning outcomes of a mental health nursing clinical practicum and to explore students’ perceptions of the clinical practicum. Design: This was a mixed-method study. Sixty-three undergraduate nursing students, who
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were undertaking their first mental health clinical practicum, completed a set of structured
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questionnaires and answered open-ended questions about the clinical practicum. Methods: Answers to open-ended questions were analyzed qualitatively, and learning outcomes (i.e., empathy, mental illness prejudice, simulation-related efficacy, and satisfaction)
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were measured at three time points: pre-clinical, post-simulation, and post-clinical. Results: Students reported improvement in empathy and simulation-related self-efficacy after
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the clinical practicum, but no change was found in mental illness prejudice. Students’ expectations for and evaluation of the clinical practicum are summarized.
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Conclusions: The observed improvement in learning outcomes of the clinical practicum may be attributed to the unique contribution of each component of the clinical practicum and the synergic effect of these diverse components. To manage emerging challenges in clinical settings and nursing education, it is critical to develop systematic and comprehensive mental health nursing clinical practicums for undergraduate nursing students. Keywords: mental health nursing clinical practicum, empathy, mental illness prejudice, simulation
ACCEPTED MANUSCRIPT Introduction Psychiatric mental health nursing clinical practicums are designed to provide nursing
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students with the opportunity to integrate necessary knowledge, skills, and attitudes toward
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the mentally ill during practice. Students engage in the psychiatric mental health nursing
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process through therapeutic relationships and communication with mentally ill patients during their clinical practicums (Perese, 1996). In addition, students confirm their understanding of mental illness by interacting with actual patients. In particular, empathy toward highly
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distressed patients is critically important in mental health nursing practicums, because an empathetic attitude is an essential component of the nurse-patient relationship (Ketola and
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Stein, 2013). Empathy is defined as an ability to understand patients’ feelings and convey their recognition accurately (Reynolds, 2000). Empathy allows nursing students to build trust,
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and mentally ill patients who recognize nursing students as empathetic feel accepted and respected (Riley, 2012). Therefore, mental health clinical practicums should be designed to
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enhance students’ empathetic abilities through various methods of education. One of the hindering factors to the development of empathy is prejudice toward
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mental illness. Prejudice is based on negative perceptions, such as the common beliefs that mentally ill persons are dangerous, unpredictable, or impossible to treat, and hamper the therapeutic relationship between nursing students and patients (Webster, 2010). Previous studies revealed that most nursing students showed a considerable level of anxiety and fear associated with prejudice related to mental illness prior to mental health clinical practicums (Hyun and Seo, 2000; Lehr and Kaplan, 2013; Perese, 1996). Quality of nursing care for patients is affected by mental illness prejudice among nurses (Noh, 2000). Hence, prejudice associated with mental illness is a critical component that must be addressed in mental health nursing clinical practicums (Chadwick and Porter, 2014; Schafer et al., 2011).
ACCEPTED MANUSCRIPT The number of nursing schools in Korea has greatly increased from 133 in 2008 to 201 in 2014 (Korean Nurses Association, 2015). With the recent rapid increase in the number
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of nursing schools, there have been significant concerns regarding the quality of nursing
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education and the lack of consensus on standardized curriculums for mental health nursing
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practicums. The increased number of nursing schools also created a shortage of settings for mental health clinical practicums. Moreover, with the increased awareness of patients’ rights and safety, opportunities for students to engage in therapeutic activities and one-on-one
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interaction with patients have been limited (Brown, 2008; Waldner and Olson, 2007).
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To address these challenges in clinical settings, simulation-based education has been applied to nursing education. Clinical simulations using standardized patients are intended to help students apply knowledge in various clinical situations and provide opportunities to
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assess and intervene mental health problems. In clinical psychiatric nursing training, simulation offers opportunities to communicate with standardized patients in a safer setting
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(Choi, 2013; Robinson-Smith et al., 2009). Moreover, simulation is helpful in reducing student anxiety when entering psychiatric units for clinical practicums. Undergraduate
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students may have their first interactions with psychiatric patients during their clinical practicums; therefore, they may not know what to expect from the patients or themselves in practice. Self-confidence and satisfaction with learning are high after simulation-based education among nursing students, because simulation provides learning opportunities in a non-threatening environment (Brown, 2008; Choi, 2013; Park and Kweon, 2012; RobinsonSmith et al., 2009). Therefore, there is an urgent need to develop and apply a mental health clinical curriculum that meets educational goals while overcoming the current challenges faced by nursing schools. The aims of this study were twofold: 1) to evaluate learning outcomes of clinical psychiatric nursing training, such as development of empathy, reduction of mental
ACCEPTED MANUSCRIPT illness prejudice, simulation-related efficacy, and satisfaction with simulation; 2) to explore students’ perceptions of clinical practicums before and after completion of a mental health
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nursing clinical practicum.
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Methods
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Clinical Course Content
The 5-week psychiatric mental health nursing clinical practicum (clinical practicum) consisted of four main components: clinical placements, psychiatric nursing simulation,
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clinical group seminars, and assignments. Psychiatric mental health nursing faculty, clinical
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instructors, and preceptors in each hospital unit (unit-based clinical education facilitators) participated in the clinical education program. The flow and components of the clinical
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Clinical placements
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practicum are summarized below.
Clinical placements took place at both psychiatric hospitals and community mental
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health centers. For diverse clinical experiences, each student spent a total of four weeks in two of the psychiatric hospital units, including adult open and closed units, a child and
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adolescent unit, and a day-hospital unit. Students also spent the last week of the clinical practicum at one of the community mental health centers. During the clinical practicum, students were required to attend meetings and therapy groups in the assigned units and directly and indirectly participate in patient care. Simulation sessions We provided two levels of psychiatric nursing simulation sessions using standardized patients: a 10-minute one-on-one communication simulation and a 20-minute complex case simulation. The 10-minute one-on-one communication simulation was designed to provide students opportunities to practice therapeutic communication skills for clients experiencing common psychiatric symptoms, such as anxiety, depression, aggression, hallucinations, and
ACCEPTED MANUSCRIPT delusions. The 20-minute complex case simulation dealt with a case of an alcoholic patient experiencing withdrawal symptoms and focused on communication with a family member
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and health care team members as well as critical thinking. Both clinical simulation sessions
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consisted of three components: orientation, clinical simulation, and debriefing. Peer-
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observation was another critical component facilitating vicarious learning among students. For the one-on-one communication simulation, each student participated in two of the four simulation cases and observed peers performing the other two simulation cases through a
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Real-time Observation Monitor (while waiting to participate). During the debriefing session,
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students had a chance to share thoughts and feelings they had during the simulation, and discuss areas for improvement. A synopsis of the scenarios and flow of the simulation
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Clinical group seminars
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sessions are summarized in Table 1.
During the 5-week clinical practicum, students attended two clinical group seminars: a
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self-understanding activity and case conference. The self-understanding activity was intended to help students understand themselves by looking back on their own childhood, past
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experiences, and relationships with significant others. For the case conference seminar, each student was prepared to discuss one clinical case that consisted of the complete assessment of a patient and prioritized nursing diagnoses with implemented nursing interventions. Students also evaluated patient outcomes of nursing interventions and shared lessons learned. Assignments During the 5-week clinical practicum, students were required to submit eight clinical reports that included critical reflective journaling. In addition, they completed a group activity report, a case study, and a report on the community mental health center. For the community mental health center report, students presented the characteristics and roles of each community center where they were placed.
ACCEPTED MANUSCRIPT Course Evaluation Design and sample
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This was a mixed-method study. To evaluate learning outcomes of the mental health
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nursing clinical practicum, we conducted a pre- and post-clinical survey with 63
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undergraduate nursing students who were undertaking their first mental health clinical practicum. Changes in empathy, mental illness prejudice, simulation-related self-efficacy, and satisfaction before and after the clinical practicum were measured using a set of
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questionnaires. Students were also asked to answer demographic questions and open-ended
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questions assessing their expectations for and satisfaction with clinical practicum. In addition, subgroup analyses were conducted by comparing data from 22 students who took the mental health clinical practicum in the beginning of the semester (Group 1) with those from 22
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students who answered the questionnaires before and after a clinical practicum for another course, which provided limited contact with patients and took place prior to the mental health
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clinical practicum (Group 2; comparison group). The data collection schedule for the main and subgroup analyses is depicted in Table 2.
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Procedure
Questionnaires were completed on the first and last day of the mental health clinical practicum, as well as immediately after the one-on-one communication simulation, which took place during the second week (Table 2). For the subgroup analyses, students in the comparison group (Group 2) were asked to complete an additional set of questionnaires in the beginning of the semester. Data were collected from March 2015 through June 2015. The study was reviewed and approved by the institutional review board of the university, and informed consent was obtained from each participant. To ensure voluntary participation, a research assistant, who was not involved in the course, obtained consent, and
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Questions about the mental health clinical practicum.
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Measurements
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Using the open-ended pre- and post-clinical questions developed by Ketola and Stein (2013), we assessed students’ anticipation regarding individuals with mental illness, opinions about how the clinical experience would affect them as nurses, and reflections on their
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personal development prior to and after the clinical practicum.
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Students were also asked to rate their expectations for and satisfaction with the clinical practicum on a scale from 1 (no expectations/very unsatisfied) to 10 (high expectations/very satisfied) before and after the clinical practicum. We also asked students whether they
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considered mental health nursing to be a career option. At the end of the clinical practicum, students were asked to rate their satisfaction with each component (i.e., psychiatric hospital
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clinical placement, community mental health center clinical placement, simulation, and group seminars) on a scale from 1 (very unsatisfied) to 5 (very satisfied).
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Empathy.
To measure empathetic capacity, we used the Empathy Construct Rating Scale developed by Monica (1981) and translated into Korean by Kim (1988). This instrument consists of 52 items, each rated on a 6-point Likert scale. The total score ranges between 52 and 312, with higher scores indicating better empathetic capacity. The Cronbach’s α for the Empathy Construct Rating Scale was .95 in this study. Mental illness prejudice. We used the Social Stigma Scale of Mental Illness Patients developed by Kim and Seo (2004) to measure prejudice toward mentally ill persons. This instrument contains 25 items grouped into four factors: dangerousness (8 items), incompetence (4 items), impossibility to
ACCEPTED MANUSCRIPT recover (8 items), and distinguishability (5 items). Three factors (dangerousness, impossibility to recover, and distinguishability) were used in our study. Each item is rated on a 4-point
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Likert scale with a total score ranging between 21 and 84. Higher scores indicate greater
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mental illness prejudice. Each subscale of the Social Stigma Scale of Mental Illness Patients
(impossibility to recover) to 0.82 (dangerousness).
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showed acceptable reliability in our sample, with Cronbach’s αs ranging from 0.769
Simulation-related self-efficacy and satisfaction.
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Simulation related self-efficacy was measured with the Post-Training Self-Efficacy
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scale developed by Ayres (2005) and translated into Korean by Park and Kwon (2012). Posttraining self-efficacy refers to belief in the ability to utilize new learning after professional education. The scale consists of 10 items on a 7-point Likert scale. The total score ranges
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between 10 and 70, with higher scores representing better post-training self-efficacy. Cronbach’s α for post-training self-efficacy was .93 in this study.
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We used the Student Satisfaction and Self-Confidence in Learning scale developed by Jeffries (2012) and translated into Korean by Park and Kwon (2012), to evaluate satisfaction
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with and self-confidence after simulation learning. Each item is rated on a 7-point Likert scale with a total score ranging between 11 and 77. Higher scores indicate higher satisfaction with education. The instrument was modified in our study to measure simulation-related satisfaction, and showed good reliability with Cronbach’s α of .90. Analysis Quantitative data were analyzed with IBM SPSS 22 (IBM, Armonk, NY 2013). Baseline characteristics of the study sample and student ratings of the clinical practicum were summarized using descriptive statistics (i.e., means, standard deviations [SD], frequencies, and ranges). Using paired t-tests, pre- and post-clinical scores on empathy and mental illness prejudice were compared in the entire sample. Changes in simulation-related self-efficacy
ACCEPTED MANUSCRIPT measured at pre-clinical, post-simulation (during the second week of clinical practicum), and post-clinical were examined using one-way repeated measures analysis of variance. A
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Bonferroni correction was used in post-hoc pairwise comparisons. We then performed
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subgroup analyses to examine changes in scores on empathy, mental illness prejudice, and
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self-efficacy before and after the clinical practicum between students who completed the mental health clinical practicum (n = 22) and those who completed clinical practicums for other courses (comparison group; n = 22) during the same period. In these subgroup analyses
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using repeated measures analysis of variance, the models included a fixed time factor (pre-
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and post-clinical), a grouping factor (mental health clinical practicum vs. nursing management clinical practicum), and a two-way interaction term between time and grouping factor. The statistical significance level was set at p < .05.
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Students’ answers to the open-ended pre- and post-clinical questions were analyzed qualitatively. After intensive review, we grouped answers with similar meanings and
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confirmed frequencies.
Results
Practicum
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Characteristics of Study Participants and Questions about the Mental Health Clinical
Among the 63 students who enrolled in the course, 52 (83%) were female. Students ranged in age from 21 to 30 years (mean 22.20 years, SD 1.88). Prior to the mental health clinical practicum, the mean score of expectations for the practicum was 7.12 (SD 1.67, median 7.00), and the average post-clinical satisfaction score was 7.82 (SD 1.91, median 8.00), which was significantly higher than the pre-clinical expectation score (t = -2.65, df = 59, p = .010). Before the clinical practicum, 32 students (51%) considered mental health nursing as a career option. Of these, four students changed their mind after the clinical practicum. Among the 31 students who did not consider mental
ACCEPTED MANUSCRIPT health nursing as a career option before the clinical practicum, 12 did so after the clinical practicum.
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Among the four clinical education components, students reported the highest
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satisfaction with the simulation (mean 4.46, SD 0.63), followed by the psychiatric hospital
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clinical placement (mean 4.29, SD 0.71) and group seminars (mean 4.11, SD 0.75). The lowest satisfaction was reported for the community mental health center clinical placement (mean 3.42, SD 1.00).
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Changes in Empathy, Mental Illness Prejudice, and Simulation-Related Self-Efficacy
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and Satisfaction
Table 3 shows mean scores on empathy, mental illness prejudice, simulation-related self-efficacy, and satisfaction before and after the clinical practicum among study participants.
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The level of empathy significantly improved from 241.84 (SD 22.77) before the clinical practicum to 255.46 (SD 24.03) after the clinical practicum (t = -6.48, df = 62, p < .001).
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There was no significant change in scores of mental illness prejudice pre- and post-clinical [mean pre-clinical score: 42.13 (SD 6.60); mean post-clinical score: 40.97 (SD 7.91); t =
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1.401, df = 62, p = .166]. Among the three subscale scores, the dangerousness score significantly decreased (representing improvement in prejudice) from 20.13 (SD 3.25) before the practicum to 17.76 (SD 3.93) after the practicum (t = 6.25, df = 62, p < .001); however, the impossibility to recover score significantly worsened from 12.94 (SD 2.91) to 13.95 (SD 3.33) (t = -2.57, df = 62, p = .013). The distinguishability score did not show a significant change after the clinical practicum (t = -0.57, df = 62, p = .57). In the repeated measures analysis of variance, we found a significant increase in levels of self-efficacy measured at preclinical, post-simulation, and post-clinical [F (2, 124) = 5.06, p = .008]. In the post-hoc pairwise comparisons, we found no significant changes from pre-clinical to post-simulation and from post-simulation to post-clinical (p’s > .05); however, the change from pre-clinical to
ACCEPTED MANUSCRIPT post-clinical was significant (p = .005). The mean score on simulation satisfaction was 64.84 (SD 6.23) immediately after the simulation and slightly increased to 66.46 (SD 7.62) after the
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clinical practicum. However, this increase was not statistically significant (t = -1.79, df = 62,
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p = .078).
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Subgroup Analyses
Table 4 summarizes the results from subgroup analyses comparing changes in scores on empathy, mental illness prejudice, and self-efficacy before and after the clinical practicum
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between students who completed the mental health clinical practicum and those in the
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comparison group. As shown in Figure 1, students who completed the mental health clinical practicum had a larger improvement in empathy scores than those in the comparison group [F(1, 42) = 6.20, p = .017]. However, there were no significant differences in changes in
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prejudice scores [F(1, 42) = 0.82, p = .37] or simulation-related self-efficacy scores [F(1, 42) = 0.49, p = .49] before and after the clinical practicum between the two groups of students.
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Among the subscale scores for mental illness prejudice, the interaction between time and grouping factor was significant for dangerousness [F(1, 42) = 10.09, p = .003], but not for
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impossibility to recover or distinguishability [F(1, 42) = 2.98, p = .092; F(1, 42) = 0.04, p = .85, respectively]. Students who completed the mental health clinical practicum showed a significant improvement in the dangerousness subscale (p = .015), while students in the comparison group showed no significant change (p = .058) (Figure 2). Qualitative Findings Quotes from the qualitative data supported the findings of the quantitative analysis that the clinical practicum enhanced empathy and simulation-related efficacy. A student (Student 16) said, “It [the clinical practicum] gave me a chance to put myself in other’s shoes and I became attentive to others’ needs.”
ACCEPTED MANUSCRIPT Regarding the clinical simulation using standardized patients with various symptoms, another student (Student 49) said,
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difficulties in interacting with psychiatric patients in the clinical rotation.” Another
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student (Student 30) said,
“In the clinical situation, I was just an observer. But, in the simulation, I could react quickly to the unexpected situation and actively participate.”
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Even though changes in the level of mental illness prejudice were not statistically
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significant after the clinical practicum, these quotes demonstrate changes in students’ perceptions toward mental illness and people with mental illness. A student (Student 43) said, “They [psychiatric patients] are not bugaboos but people like us. If they control their
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acting out, they can socialize with us.” Moreover, another student (Student 11) said, “I became interested in people with mental illness. My prejudice decreased with the
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clinical practicum, and it lessened my resistance to the mentally ill. Not all psychiatric patients are aggressive.”
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Additional qualitative findings of student expectations for and satisfaction with the clinical practicum are summarized in Table 5. Discussion
This paper introduced an example of a curriculum for an undergraduate mental health nursing clinical practicum. We also evaluated learning outcomes of the clinical practicum and explored students’ perceptions of the clinical practicum. In our study, the level of empathy among students significantly improved after the clinical practicum. Improvement in empathy was also significant in a subgroup analysis comparing two groups: students who completed the mental health clinical practicum and those in another course. Brunero et al. (2010) showed that the level of empathy or empathy skills among
ACCEPTED MANUSCRIPT nursing students significantly improved after a skills-based course, undergraduate courses, an art program, and special education/training programs. Therefore, in our study, diverse
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teaching strategies, including exposure to diverse clinical settings, experiential learning (i.e., a
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psychiatric nursing simulation using standardized patients) and activities enhancing self-
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reflection such as a self-understanding activity and critical reflective journaling, may have contributed to the increase in empathy among nursing students. Scholars (Brunero et al., 2010; Ward et al., 2012) have recommended that simulations or role-playing with standardized
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included in empathy education in nursing.
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patients and learning activities enhancing self-awareness and self-reflection should be
Empathy is a critical component in the development of the therapeutic nurse-patient relationship and is beneficial to both patients and nurses; therefore, improving empathy
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among nursing students is of importance. In particular, the cognitive aspect of empathy (i.e., perspective taking) is positively associated with work engagement and job satisfaction, and
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negatively with turnover intention among nurses (Pohl et al., 2014). With technology advances and the increasing importance of cost-effectiveness in health care, the focus of
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nursing has shifted from providing person-centered care to mastering technical skills and advanced knowledge (Heller et al., 2000; Huston, 2013). Furthermore, changes in health care environments and nursing education have affected the development of empathy. Ward et al. (2012) reported a counterintuitive decline in the level of empathy among undergraduate nursing students, particularly those with more clinical encounters with patients. Thus, nursing education that enhances empathy is needed. Another expected learning outcome of the present study was decreased mental illness prejudice among nursing students. In our study, the level of mental illness prejudice did not change among nursing students after the mental health clinical practicum. In the analysis of prejudice subscales, while the scores on dangerousness improved, scores on impossibility to
ACCEPTED MANUSCRIPT recover worsened. In other words, students perceived individuals with mental illness as less dangerous after the clinical practicum, whereas they became less hopeful for recovery from
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mental illness after the clinical practicum. These findings are consistent with those of
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previous studies (Bae, 2002; Yang and Yu, 2001). Students’ answers to open-ended questions
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reflected changes in their perceptions toward the dangerousness of people with mental illness, reporting that they learned not all psychiatric patients are aggressive and psychiatric patients could socialize with others.
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The finding that students became less hopeful for recovery from mental illness after
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the clinical practicum is not surprising. In Hugo’s study (2001), mental health professionals were more pessimistic about recovery from mental illness than the general public. He reported that health care professionals’ negative views are possibly based on a more realistic
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assessment and are associated with their own experiences with mental health problems. In his study, all mental health professionals believed that persons with mental illness would recover
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partially or fully if they received professional help. Overall, no significant change in mental illness prejudice after the clinical practicum
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was noted in our study. The 5-week clinical practicum might not have been enough to cause changes in mental illness prejudice deeply rooted in social values (Pescosolido, 2013). Corbiere et al. (2012) claimed that reducing the prejudice of mental illness requires diverse strategies, such as public education/teaching, normalizing, working on recovery by supporting and encouraging the mentally ill, and contact with people with mental illness. Thus, it is believed that diverse approaches at different levels beyond the clinical practicum are needed to fight the prejudice of mental illness. In our study, students exhibited significantly improved simulation-related self-efficacy after the practicum. In addition, regarding satisfaction with the clinical practicum, students rated the clinical simulation highest among all components. Students reported that the
ACCEPTED MANUSCRIPT simulation enabled them to practice therapeutic communication skills in a safe environment and thus built up their confidence in interacting with patients exhibiting psychiatric symptoms.
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Previously, Kameg et al. (2010) reported that a clinical simulation was effective in improving
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student self-efficacy regarding communication skills.
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Students also reported that the various cases and debriefing sessions of the clinical simulation allowed them to explore personal behaviors, beliefs, and attitudes toward psychiatric patients and to identify their own strengths and weaknesses as a nurse. This
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finding is consistent with Brown (2008) who found that a clinical simulation helped students
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to develop an in-depth understanding of themselves. Thus, self-reflective experiences might contribute to increased empathy among nursing students. Overall, the clinical practicum had positive effects on undergraduate nursing students’
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experiences with mental health nursing education and produced desirable learning outcomes. The findings of the present study inform future directions for mental health nursing
1.
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practicums. Suggestions are as follow: Develop agreed-upon core components of clinical practicums and teaching strategies
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for accomplishing core competencies of mental health nursing education. While core competencies of nursing education have been developed, there is no consensus on the core components of mental health nursing clinical practicums. 2.
Continue to incorporate clinical simulations into mental health nursing practicums. Clinical simulations appear to be effective in improving self-efficacy and generating high student satisfaction. For future clinical practicums, it is important to develop structured simulation scenarios with diverse cases and scenarios that require different levels of clinical competencies.
3.
Develop standardized assessment tools to assess the quality of mental health nursing practicums and to evaluate learning outcomes. Development of systematic and reliable
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Conclusion
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The findings of this study showed evidence that a 5-week mental health nursing
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clinical practicum improved empathy, simulation-related self-efficacy, and one aspect of mental illness prejudice among nursing students. Overall, students were satisfied with the clinical practicum experience, particularly the clinical simulation using standardized patients.
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We believe that the observed improvement in learning outcomes can be attributed to a unique
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contribution of each component of the clinical practicum and the synergic effect of those diverse components. Therefore, to manage emerging challenges in clinical settings and nursing education, it is critical to develop systematic and comprehensive mental health
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nursing clinical practicums for undergraduate nursing students.
ACCEPTED MANUSCRIPT References Ayres, H.W. 2005. Factors related to motivation to learn and motivation to transfer learning in
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a nursing population. (Doctorial dissertation), North Carolina State University, USA.
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Retrieved from http://repository.lib.ncsu.edu/ir/bitstream/1840.16/3773/1/etd.pdf
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Bae, J., 2002. A study on the stress and recognition for psychiatric patients of nursing students during the clinical experience in psychiatric unit. Journal of Korean Academy of Psychiatric and Mental Health 17(1), 411-424.
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Brown, J., 2008. Applications of simulation technology in psychiatric mental health nursing
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education. Journal of Psychiatric and Mental Health Nursing 15(8), 638-644. Brunero, S., Lamont, S., Coates, M., 2010. A review of empathy education in nursing. Nursing Inquiry 17(1), 65-74.
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Chadwick, L., Porter, J., 2014. An evaluation of the effect of a mental health clinical placement on the mental health attitudes of student nurses. Nursing and Health 2(3), 57-
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64.
Choi, Y.-J., 2013. Standardized patients for Korean psychiatric nursing student simulations.
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Clinical Simulation in Nursing 9(9), e385-e392. Corbiere, M., Samson, E., Villotti, P., Pelletier, J.-F., 2012. Strategies to fight stigma toward people with mental disorders: perspectives from different stakeholders. The Scientific World Journal 2012, 1-10. doi:10.1100/2012/516358 Heller, B.R., Oros, M.T., Durney-Crowley, J., 2000. The future of nursing education. Ten trends to watch. Nurs Health Care Perspect 21(1), 9-13. Hugo, M., 2001. Mental health professionals’ attitudes towards people who have experienced a mental health disorder. Journal of Psychiatric and Mental Health Nursing 8(5), 419-425. Huston, C., 2013. The impact of emerging technology on nursing care: warp speed ahead. Online J Issues Nurs 18(2), 1.
ACCEPTED MANUSCRIPT Hyun, M., Seo, M., 2000. Clinical practicum experiences of the nursing students in psychiatric settings. Journal of Korean Academy Psychiatric Mental Health Nursing, 44-
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53.
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2nd ed. National League for Nursing, New York, NY.
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Jeffries, P.R., 2012. Simulation in nursing education: From conceptualization to evaluation,
Kameg, K., Howard, V.M., Clochesy, J., Mitchell, A.M., Suresky, J.M., 2010. The impact of high fidelity human simulation on self-efficacy of communication skills. Issues in Mental
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Health Nursing 31(5), 315-323.
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Ketola, J., Stein, J., 2013. Psychiatric clinical course strengthens the student–patient relationships of baccalaureate nursing students. Journal of Psychiatric and Mental Health Nursing 20(1), 23-34.
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Kim, J., Seo, M., 2004. A study on prejudice and discrimination against the mentally ill. The Korean Journal of Health Psychology 9(3), 589-607.
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Kim, M.S., 1988. Reliability and validity of a Korean empathy construct rating scale. The Journal of Nurses Academic Society 18(1), 26-33.
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Korean Nurses Association. (2015). Nursing schools in Korea. Retrieved from http://www.koreanurse.or.kr/resources/be_nurse.php Lehr, S.T., Kaplan, B., 2013. A mental health simulation experience for baccalaureate student nurses. Clinical Simulation in Nursing 9(10), e425-e431. Monica, E.L.L., 1981. Construct validity of an empathy instrument. Research in Nursing & Health 4(4), 389-400. Noh, C., 2000. Comparative study on the cognition and attitudes toward mental illness among nursing college students. Journal of Korean Academy Psychiatric Mental Health Nursing 9(2), 145-155.
ACCEPTED MANUSCRIPT Park, S., Kweon, Y., 2012. The effect of using standardized patients in psychiatric nursing practical training for nursing college students. Journal of Korean Academy Psychiatric
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Mental Health Nursing 21(1), 79-88.
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Perese, E.F., 1996. Undergraduates' perceptions of their psychiatric practicum: Positive and
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negative factors in inpatient and community experience. Journal of Nursing Education 35(6), 281-285.
Pescosolido, B.A., 2013. The public stigma of mental illness: What do we think; What do we
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know; What can we prove? Journal of Health and Social Behavior 54(1), 1-21.
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Pohl, S., Saiani, L., Battistelli, A., 2014. Empathy in the emotional interactions with patients. Is it positive for nurses too? Journal of Nursing Education and Practice 4(2), 74-81. Reynolds, W., 2000. The measurement and development of empathy in nursing. Ashgate,
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Aldershot, UK.
Riley, J.B., 2012. Communication in nursing, 7th ed. Elsevier Health Sciences, St. Louis,
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MO.
Robinson-Smith, G., Bradley, P.K., Meakim, C., 2009. Evaluating the use of standardized
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patients in undergraduate psychiatric nursing experiences. Clinical Simulation in Nursing 5(6), e203-e211.
Schafer, T., Wood, S., Williams, R., 2011. A survey into student nurses' attitudes towards mental illness: Implications for nurse training. Nurse Education Today 31(4), 328-332. doi:10.1016/j.nedt.2010.06.010 Waldner, M.H., Olson, J.K., 2007. Taking the patient to the classroom: Applying theoretical frameworks to simulation in nursing education. International Journal of Nursing Education Scholarship 4, Article18. doi:10.2202/1548-923x.1317
ACCEPTED MANUSCRIPT Ward, J., Cody, J., Schaal, M., Hojat, M., 2012. The empathy enigma: An empirical study of decline in empathy among undergraduate nursing students. Journal of Professional
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Nursing 28(1), 34-40. doi:10.1016/j.profnurs.2011.10.007
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Webster, D., 2010. Promoting empathy through a creative reflective teaching strategy: A
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mixed-method study. Journal of Nursing Education 49(2), 87-94.
Yang, S., Yu, S.J., 2001. The stigma toward the mental illness and mentally ill patients among nursing students between before and after learning psychiatric mental health nursing.
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Journal of Korean Academy Psychiatric Mental Health Nursing 10(3), 421-435.
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Table 1. Synopsis of simulation scenarios and flow of the simulation sessions Synopsis of Simulation Scenarios
Communication
A 30-year-old male patient with schizophrenia refuses to take
Scenario 1:
medication due to auditory hallucinations and persecutory
Schizophrenia
delusions.
Communication
A 53-year-old female patient with generalized anxiety disorder
Scenario 2: Generalized
walks back and forth and exhibits excessive anxiety, worry,
anxiety disorder
and restlessness.
Communication
A 27-year-old female patient with borderline personality
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personality disorder
room to work on origami as she wishes.
Communication
A 43-year-old female, whose son drowned during a family
Scenario 4: Major
camping trip six months ago, exhibits depressed mood, loss of
depressive disorder
energy, excessive guilt, insomnia, and suicidal ideation.
Complex case scenario
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Scenario 3: Borderline
A 53-year-old male patient is admitted to the emergency room with multiple abrasions and possible fractures after falling
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down the stairs. He has been drinking a bottle of vodka almost
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every day for more than 10 years and started drinking heavily after retiring from work about two and a half years ago. While
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waiting to be seen by an orthopedic surgeon, he begins to
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experience acute alcohol withdrawal symptoms and delirium tremens. As a primary nurse, the student is expected to provide
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care for the patient and communicate with his wife who denies her husband’s alcohol problem and refuses his admission to the
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psychiatric unit. Flow of Simulation Sessions
Communication Communication Communication Communication Scenario 1
Scenario 2
Scenario 3
Scenario 4
Group 1
Participation in the simulation
Real-time observation
Group 2
Real-time observation
Participation in the simulation
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Table 2. Clinical practicum and questionnaire completion schedule
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Group 1
2
Weeks 3
Weeks 4
5
6
7
8
Weeks 9
10
Psychiatric mental health clinical practicum
Questionnaire ↑a,d Group 2
↑b
Control group
↑c,e Psychiatric mental health clinical practicum
Questionnaire ↑d
↑a,e
↑b
↑c
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12 12
13
14
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Group 3
clinical practicum ↑a
↑b
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Questionnaire
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↑ indicates questionnaire completion. a,b,c
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Pre-clinical, post-simulation, and post-clinical measurements for the main analyses.
d,e
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Pre- and post-clinical measurements for the subgroup analyses.
↑c
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Post-simulation
Post-clinical
p-value
241.84 ± 22.77
Not measured
255.46 ± 24.03
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< .001
42.13 ± 6.60
Not measured
40.97 ± 7.91
.166
Self-efficacy
57.51 ± 5.46
59.54 ± 8.18
60.38 ± 6.31
.008
Satisfaction
Not measured
66.46 ± 7.62
.078
Empathy
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Mental illness
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Pre-clinical
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Table 3. Mean empathy, mental illness prejudice, simulation-related self-efficacy, and satisfaction scores at pre-clinical, post-simulation, and post-clinical in the study sample (n = 63)
a
prejudice
64.84 ± 6.23
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Higher scores represent worse mental illness prejudice.
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P-values are for paired t-tests (empathy, prejudice, and satisfaction) or for one-way repeated measures analysis of variance (self-efficacy).
ACCEPTED MANUSCRIPT Table 4. Comparisons of empathy, mental illness prejudice, and simulation-related selfefficacy scores before and after the clinical practicum between students who completed the
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psychiatric mental health nursing clinical practicum and those in the comparison group Psychiatric mental health nursing
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Comparison group clinical practicum
p-
Pre-clinical
Post-clinical
Pre-clinical
Post-clinical
245.23 ± 21.51
257.55 ± 20.26
241.23 ± 20.42
241.27 ± 21.11
.017
39.95 ± 4.43
40.59 ± 6.91
42.50 ± 8.58
44.59 ± 7.24
.371
58.14 ± 6.80
61.59 ± 5.10
55.50 ± 8.12
57.41 ± 5.33
.486
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Empathy
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Mental illness
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prejudicea Self-efficacy
P-values are for repeated measures analysis of variance.
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Higher scores represent worse mental illness prejudice.
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a
value
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(n = 22)
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Expectations before the clinical practicum
Observation of mental health nursing practice; development of rapport,
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The clinical practicum will provide me with the following opportunities:
communication with patients, keeping the therapeutic milieu for patients (24.2%) Observation of and understanding psychiatric symptoms (21.9%)
Development of fundamental nursing competencies; therapeutic communication skills,
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nursing roles, managing patients with emotional problems (19.6%) Exploration of career options (9.4%)
Improvement of communication skills (7.8%)
A unique experience to satisfy my curiosity (4.7%)
Self-reflection (3.9%)
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Evaluation of the clinical practicum
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The clinical practicum provided me with the following opportunities: Development of competency in using the self as a therapeutic tool for patients; communication with patients, sharing their emotions, practicing direct patient care (16.4%)
Practice of therapeutic communication skills (14.1%)
Change in my perspectives on nursing; consideration of the emotional aspects of physically ill patients and the importance of treating patients as human beings (14.1%)
Self-reflection (11.7%)
Understanding psychiatric symptoms and the mental illness process (7.1%)
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Reduction of prejudice regarding mental illness (7.1%)
Observation of direct nursing care provided by mental health nurses (3.9%)
Improvement in understanding of human beings (3.9%)
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Fig. 1 Pre- and post-clinical empathy scores in students who completed the psychiatric mental health clinical practicum and those in the comparison group
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[Attached as a separate file]
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Fig. 2 Pre- and post-clinical dangerousness subscale scores in students who completed the psychiatric mental health clinical practicum and those in the comparison group (higher scores represent worse mental illness prejudice)
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[Attached as a separate file]
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION CLINICAL EDUCATION IN PSYCHIATRIC MENTAL HEALTH NURSING:
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OVERCOMING CURRENT CHALLENGES
Heeseung Choi, PhD, MPH, RN1, Boyoung Hwang, PhD, RN1*, Sungjae Kim, PhD, RN1,
College of Nursing & The Research Institute of Nursing Science, Seoul National University,
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1
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Heesung Ko, PhD(c), MSN, RN2, Sumi Kim, PhD(c), MA, RN2, Chanhee Kim, MSc, RN2
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Seoul, Korea; 2College of Nursing, Seoul National University, Seoul, Korea
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Source of funding: None.
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Conflicts of interest: None.
*Address for Correspondence:
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Boyoung Hwang, PhD, RN, College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, Korea 110-799; E-mail: [email protected]
Word count: 5,000 words (including references and abstract)
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ACCEPTED MANUSCRIPT PSYCHIATRIC MENTAL HEALTH NURSING CLINICAL EDUCATION Highlights: We evaluated learning outcomes of a mental health nursing clinical practicum. Sixty-three students completed a 5-week mental health nursing clinical practicum.
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The clinical practicum improved empathy and simulation-related self-efficacy. No change was found in mental illness prejudice after the clinical practicum.
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The present study informs future directions for mental health nursing practicums.
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