Introduction

With the rapid and complex changes occurring in both health care and nursing education, student Registered Nurses interested in a career in mental health face unprecedented challenges in psychiatric clinical practice environments. Few psychiatric agencies today have escaped cutbacks, downsizing and restructuring of provision of services. In nursing education, revolutionary curricular changes have occurred in response to delivering programs of study through colleges and universities rather than hospital based schools. Compounding the hurdle of learning from a new curriculum in clinical areas undergoing turbulent organizational restructuring, students now see fewer Registered Nurses choosing to practice in the psychiatric speciality. Research related to clinical teaching in psychiatric mental health is limited and further study is essential in order to develop approaches which explain and promote the field. In this paper, we examine the process of learning psychiatric mental health nursing through the eyes of one student who hopes to work in the area.

Literature Review

A serious lack of interest in pursuing psychiatric nursing as a career option exists among Registered Nurses graduating from baccalaureate programs (Amswald, 1987; Perese, 1996; Rushworth & Happell, 1998). Amswald (1987) reported that fewer and fewer nurses were choosing psychiatric nursing for both employment and graduate study

Following an analysis of the research literature, she suggested that the integration of psychiatric nursing into general nursing curricula and a negative undergraduate experience in the psychiatric clinical area were the two factors most responsible for the disinterest (Amswald, 1987), Perese (1996) asserted that “the decline in the number of students selecting psychiatric nursing as a preferred practice area from a three decade level of 5% to the present 3% (Francell, 1990. p.163) is ominous” (p.281). Furthermore, Rushworth and Happell (1998) concluded that “Psychiatric nursing is not a popular career choice among undergraduate nursing students” (p.324).

Research offers educators and practitioners little guidance in resolving the current problem of disinterest in the field. Early psychiatric nursing research studies in clinical teaching centred on measuring students’ attitudes towards psychiatric patients. For example. Holmes, Klein, Stout and Rosenkranz (1975) and Bairan and Farnsworth (1989) measured how psychiatric courses, particularly those providing an in-patient hospital practicum, were effective in favourably changing nursing students’ attitudes towards mental illness. Using the Opinions About Mental Illness (OMI) scale, these investigations affirmed that traditional six or eight week nursing courses, which focused exclusively on psychiatric content, made a significant difference in the way student nurses felt about their psychiatric patients. The findings were similar to five previous healthcare investigations rising the OMI (Creech, 1977; Gelfand & Ullmann, 1961; Lewis & Cleveland, 1966; Morris, 1964; Smith, 1969) in that psychiatric courses reduced attitudes which stigmatized the mentally ill.

Later, Schoffstall (1981), Krikorian and Pavlanka (1984), and Yonge and Hurtig (1987) invited students to discuss their perceptions of their psychiatric clinical experiences through open-ended questionnaires. Their findings revealed that when students spent six weeks immersed in courses dedicated exclusively to psychiatric nursing, they generally entered their practicum with trepidation, but emerged with a sense of recognition that the experience had provided an opportunity to develop both personally and professionally. Schoffstall (1981) found that students were initially concerned about their own ability to cope and contribute. They expressed fear about physical danger, concern about being similar to psychiatric clients, worries about psychiatric clients being stereotyped as ‘different,’ and apprehension that the experience might be emotionally painful. Krikoran and Pavlanka (1984) reported that students’ “overwhelmingly identified clinical experience and self-awareness as the primary change-producing factors in their education, and lectures / readings / assignments, teachers and peers as secondary” (p. 124). Yonge and Hurtig’s (1987) findings differed slightly in dial the teacher was identified as the most influential change agent, with patients rated as second.

Similarly, reflecting on student comments following their traditional psychiatric rotation, Marley (1980) noted that students often approach their psychiatric rotation with feelings of “high anxiety, … fear [of] being hurt emotionally and physically … and wonder what they will do if a patient should reject them” (p.16). Illustrating the emotional intensity students experience during psychiatric practicums, Marley (1980) suggested that “about two students out of ten, of each rotation, seek counselling for their own inner turmoil” (p.20). She emphasized the importance of instructor, peer, and staff interactions to facilitate meaningful learning throughout this unique rotation

Contemporary’ mental health courses in baccalaureate Registered Nursing programs can differ dramatically from traditional hospital diploma programs. Traditionally, diploma students spent six or eight weeks immersed in classes and clinical practice focusing almost exclusively on psychiatric nursing content. By contrast, today, in baccalaureate programs, content related to advanced medical – surgical nursing, community healthcare and optional university courses arc often delivered concurrently with a psychiatric clinical practicum. Students no longer live in hospital nurses’ residences. They may be employed adult learners returning to academia or single parents supporting families. Practicum placements are not expected to be confined to hospital units. DeLaGarza and Martinez-Rogers (1996) described how a run-down Texas mission house provided a valuable psychiatric learning exprerience for students. Slimmer, Wendt and Martinkus (1990) wrote about assigning students to a community Veterans Medical Centre and a private hospital. Perese (1996) placed students in a Continuing Treatment Centre and a Psychosocial Club.

Although current literature addressing leaching and learning in the psychiatric mental health clinical area does provide useful instructional strategies, exploring the experience from a student’s perspective has generally been overlooked. For example, Arnold and Nicswiadomy (1997) described a pre-clinical exercise to reduce student anxiety; Mingelle and Benson (1995) explained critical incident analysis as a way of helping students debrief; McAllister (1995) suggested the metaphor of students visualizing themselves as tour guides; Landeen, Byrne and Brown (1995) noted the value of reflective journal writing and Armstrong and Pieranunzi (2000) created weekly interpretive exercises to supplement student learning. However, in addition to constructing these kinds of innovative practicum placements and instructional strategics, it is important to try and understand the experience of foaming psychiatric nursing from a student’s perspective.

Clearly, students today face different and overwhelming demands that compete with their nursing education. In addition to the classic concerns Scholffstall (1981) identified that students who typically must also travel farther to clinical placements, orient to new surroundings more frequently, and continue to maintain their personal and family responsibilities. We may no longer presume that clinical practice sites are in a position to easily integrate students into staff groups. In response to restructured workplaces, practitioners also find their own time is stretched in different ways and opportunities to guide and mentor novices are not straightforward. Given the current disinterest in mental health specialization, it is essential to gain insight into clinical experiences which engage students, to understand what students find difficult and to aggressively promote the image and desirability of the field. This project has been an attempt to learn about the experiences and perceptions of student nurses during the psychiatric portion of their nursing education program.

Methodology

In an effort to understand the nature of today’s undergraduate psychiatric practicum from a student’s point of view, we followed “Heather” (a pseudonym she chose herself), through her clinical rotation at a provincial mental institution site. We used a constructivist conceptual research perspective, where observers are included in the domain of the observed and the focus is on process and pattern, and qualitative methodology to create a collaborative case study report of her experience. Data sources included before and after repertory grids (Kelly 1955/1991), a questionnaire (Perese, 1996) and audiotape recorded transcribed the interviews. Content was theme analyzed (Berg, 1995), Vee Heuristic diagrammed (Novak and Gowin, 1984) and concept mapped (Novak and Gowin, 1984). The case study was written collaboratively with the student. Ongoing interaction and member checking six months after the practicum ended by confirming the trustworthiness and authenticity of the work. The report of Heather’s experience is part of a larger three year project which included five other students, a pilot study and the incorporation of findings into a clinical curriculum (Melrose. 1998; Melrose & Shapiro, 1999). The “story” which follows is a snapshot portrayal of one student. Heather, and what it was like for her to learn about psychiatric nursing.

Heather’s Story

Heather is an aduli student who completed a Bachelor of Arts degree before enrolling in the Faculty of Nursing. She majored in psychology and one of her reasons for choosing nursing was that a “career counsellor told me about psychiatric nursing, and I thought it might fit with my degree.”

Heather was the only member of the study group who expressed an interest in pursuing the field of psychiatric mental health nursing. She chose to complete her clinical experience at a provincial mental institution, The site was about a three-hour drive out of town. Throughout the six-week clinical placement, students and their clinical instructor drove out individually to the facility on Thursday mornings. They met as a group for a preconference, joined the unit staff for a two to ten shift that evening and then spent the night in a two-room staff “house” located on the hospital grounds. On Friday mornings, the students and their instructor were part of the day shift from seven to three, attended a post conference and then went their separate ways to drive home Friday evening. Canadian winter driving conditions were often unpredictable and Heather’s clinical instructor frequently arranged a “cavalcade of cars” and ensured that “someone had a cell phone when we were on the highway.” The students who chose this placement were a self-selected group, many of whom “knew each other before the experience.” One of the students in Heather’s group commented that: “We wanted the best experience and we knew this was it.” Heather earned a clinical grade of A in her practicum and shortly after the course began, her clinical instructor noticed that she was a “strong student.” Heather was single and her family lived out of province. She boarded in Calgary and worked twenty to forty hours a week as a waitress during her program.

At the end of the course. Heather continued to be interested in the field of psychiatric mental health nursing. She indicated that she felt she left the experience with “more questions” about the area and wondered what working in “forensic psychiatry or with teenagers in schools” might be like. The clinical placement was her “favourite so far” and she described it as “excellent interesting and stimulating.” For Heather, the process of engaging and sustaining her interest in the field revolved around two main themes. The first theme was clarifying her personal and professional growth and the second theme was discovering the need for reflective time.

Theme One: Making Distinctions: Clarifying her Own Personal and Professional Growth

When Heather first arrived on her assigned unit, she stated that she felt “insecure” in the stark “bare” environment. Handed a set of keys, she was immediately drawn into the institutional protocol of unlocking and “securing” the heavy hospital doors. Nevertheless, she felt welcome and included by the hospital staff group and sensed that a spirit of community existed between staff and patients. On acute psychiatric wards in urban, general hospitals, where several of Heather’s classmates completed their clinical experiences, professional staffs often dress in ways that make them indistinguishable from their patients. However, in this particular provincial institution setting, several of the patients wore hospital pyjamas and robes and many wore slippers rather than street shoes. Some staff members wore large badges with their name and affiliation and all staffs were required to carry keys. Unlike her peers in city hospital placements, who described feeling unsure about how to become involved in a psychiatric milieu. Heather immediately sensed that she was a part of the staff team. She was struck by the “silence” of the facility and as she looked at the patients, she thought: “I see the people here as sick, I feel bad and I want to help.” Yonge and Osborne (1991) interviewed nurses who worked at this particular facility during two time periods, the first was between 1950 and I960 and the second between 1970 and 1991. After listening to the nurses, the authors concluded that psychiatric nursing in this provincial hospital was “more than a job, [it was] a way of life, a way of knowing what was really important to people whether you were a patient or a staff member” (p.11). Yonge and Osborne (1991) summarized the work environment of this institution as follows: “It wasn’t easy work and for some it gave financial security, but after a while those things don’t matter as much as your feeling of belonging” (p.11). Heather expressed a sense of this feeling of belonging and subsequently found the concept of a therapeutic milieu “easier” to understand. The day Heather was interviewed on her clinical unit mid-way through the course, she talked about how her own learning was progressing. In particular, she commented on two issues she was in the process of working through. The first centred on establishing therapeutic boundaries. The second involved clarifying the tasks of the nursing role. She found it difficult to distinguish activities specific to nursing from activities implemented by other professional group, such as social workers and occupational therapists. Describing concerns with the first issue, Heather questioned how she could establish therapeutic boundaries with an “infatuated” female patient “who likes me and fellows me around.” Heather wondered how to “cope with the frustration and burnout” when a patient “can be admitted 35 times.” Another patient told Headier that “I’m not getting the help I need here.” As she struggled to move beyond simply’ supporting her patients and to help them therapeutically. Heather found herself feeling “upset, exhausted, funny, and disjointed” when she left the clinical laboratory.

As Heather reflected on the second issue of separating activities specific to nursing from those of other professional staff groups, she looked at the activities she saw nurses engaging in. She observed: “They’re always busy, but I’m not sure what they’re doing.” Heather noticed that psychiatric mental health nurses “spent a lot of time advocating for patients when they were on the phone with physicians.” She saw nurses “locking, unlocking and checking the doors a lot” Heather admired one nurse who “had the patients all making chilli in the kitchen” one evening. Similarly, she appreciated how another nurse “sat and looked at pictures” with a patient. Piecing together the unique nature of mental health nursing. Heather did not have a clear picture of what the role of the psychiatric nurse entailed:

I wonder what the nursing role really is. We’re not trained in some things. The social workers deal with child abuse, the occupational therapists arrange outings like bowling. I think it would be nice if nurses were more involved.

During the mid-term interview, in addition to discussing the difficulty she experienced in the process of learning about therapeutic boundaries and the nature of the psychiatric nurse’s role, Heather also mentioned that she was enjoying her experience and “learning a lot.” She did not observe any “cruelty” or “nurses talking down to patients.” She felt that she had “help” with strategies to establish the necessary boundaries in her relationships with patients. She also felt that she was developing a deeper understanding of what a therapeutic milieu “feels like.” Joining staff and patients on outings away from the institution. Heather enjoyed the rapport she felt with the staff-patient group: “Going into town for bowling was fun. On the bus ride, we had the music turned up loud and we were all singing together.”

Theme Two:  Discovering the Need for Reflective time

As noted above, the first theme which emerged in this investigation of Heather’s learning experience was a thoughtful process of making distinctions as she clarified her own personal and professional growth. The second theme involved discovering the need for reflective time, in concert with her existing interest in the field and die feeling of inclusion which she experienced during her practicum.

Heather indicated that her identity as a novice psychiatric nurse became more developed as she completed her rotation. However, in addition to her clinical practicum, she found driving six hours each week and keeping up with a job and her other university course requirements very exhausting. She described waking up one morning “not knowing right away whether I was at clinical, at the restaurant or at home!”

Time to reflect and interpret the new ideas and knowledge she was seeking to assimilate was essential to the richness of the clinical experience for Heather and she remarked on its absence in her program, due to all of the demands on her time. Brookfield (1990) criticized higher education experiences which neglect “praxis, that is ensuring that opportunities for the interplay between action and reflection are available in a balanced way for students” (p.50). Brookfield (1990) asserted that higher education curricula typically “rush through masses of content and … assign (tasks which measure) familiarity with that content so thick and fast that there is barely time to assimilate new ideas and knowledge” (p.50). He encouraged students and all those involved with their education to take lime for “mulling over … and making interpretive sense of what is happening to them” (p.50). The course curriculum provided Heather and her fellow students with an opportunity to share their feelings by designating group post conferences. However, as Heather explained:

Working two to ten, up the next day at five-thirty in the rooming, work until three and then the drive home — it just didn’t lend itself much time to rest. By the time post conference rolled around, we were all pretty tired. Then, it’s over and you’re alone again.

It was difficult for her to create a space within the clinical practicum to process and interpret all of the new information she was exposed to. Through the experience of sharing overnight accommodation with fellow students and her clinical instructor, Heather found she valued informal debriefing discussions and that the opportunity to talk about her experience stimulated reflection:

I know nursing used to be like this. You’d be in a residence of nurses and personally I know for all my rotations that would really help me because when I talk about nursing, that’s when I learn the most. I’m not around nurses a lot because of my job and where I live. It was great to be totally focused in that environment. I thought that environment was excellent.

After the course was over. Heather commented on what stood out for her:

Just how exhausted I could be after playing cards or going tor walks. You’re always thinking. You’re always trying to assess (patients) and you’re using so much of your mind. It’s draining! That stood out for me. I had a patient cry with me and I was just shaking. I have never experienced anything like that before, except with my friends, but never in a therapeutic way. I was shaking. I didn’t know what to do. I talked her through it and I fell fine until after and then I felt like crying because it really affected me. Some days I’d go home and feel really depressed and kind of disjointed almost, not all together.

These comments reflect the contrast between psychiatric nursing and mainstream nursing. Even Heather’s familiarity with knowledge from both nursing and psychology did not provide her with a way of framing the emotionally charged learning experiences she faced in the practicum. She had “never experienced anything like that before” and it was “really different.” Her course lectures linked concepts in medical surgical nursing to similar concepts in psychiatric nursing in her integrated course, but Heather often found this “confusing.” Terms which “fit” in other clinical areas seemed to have little relevance in this rotation. She was struck by how different the experience was and although she “loved it,” she also “needed time to sort it all out.”

In summary, Heather demonstrated striking changes in her understanding of psychiatric nursing during her practicum at a provincial mental institution. She was motivated by and interested in the field before the course even began. She grew personally and professionally and valued the affirmation she received as she learned to establish therapeutic boundaries with her patients. She also learned to define the psychiatric nursing role in a personally relevant way. It was vitally important for her to have time to reflect and discuss her emotional responses and the profoundly different nature of the experience.

Discussion

Together, the two themes of clarifying her own personal and professional growth and discovering the need for reflective time illustrate one student’s experience learning psychiatric nursing. Unlike many student Registered Nurses who have little if any interest in a career in psychiatric mental health nursing. Heather entered her practicum with the intention of pursuing work in the field. Moir and Abraham (1996) examined how six final year undergraduate nursing students at a Scottish university who chose the psychiatric speciality area as a career justified their choice and constructed an occupational identity. Moir and Abraham (1996) found that although these novice psychiatric nurses believed a general nursing career path offered more rewards, they also viewed mainstream nursing “as technical … involving routine task completion (and a career which) curtailed opportunities to form relationships with patients or provide investigative and diagnostic challenges” (p.297). By contrast, they saw the less structured psychiatric field as more challenging because of “the lack of established knowledge … the professional autonomy … and the sociability (inherent within) the psychological nature of psychiatric nursing” (p. 298). However, the researchers did not comment on whether or not the students in their findings indicated that novice psychiatric nurses had clear constructions of their occupational identity by their final year of study. This identity developed through a process of contrasting psychiatry with general nursing. Extracts from conversations with the students in Moir and Abraham’s (1996) research reveal how students who chose the psychiatric field felt “included … valued … and listened to” in psychiatric settings but simply “measured on how quickly you can do things” in medical surgical areas (p.297). Similarly, in the present study, Heather emphasized the “difference” of the practicum and how she quickly felt a strong sense of identity within the psychiatric area.

Heather’s positive experience leads us to question how other Registered Nursing students can be provided with attractive and valuable learning opportunities in mental health nursing. Theme one in Heather’s story illustrates the importance of preparing and organizing resources for students to turn to as they sort out and clarify the special kinds of personal and professional growth which can occur in this unique area. To ensure that support is available to students, university nursing curricula must acknowledge the contrasting nature of the field, introduce adequate psychiatric content and orient students throughout their programs by facilitating increased student contact with mental health practitioners. Also, practitioners must understand the changing nature of students’ educational experiences and make certain that activities which welcome and involve them are made available. Theme two in Heather’s story emphasizes the essential need to create more time to talk with students and to encourage their reflections. What does the world of psychiatric mental health nursing look like to a novice? A plethora of exciting possibilities emerge when we create opportunities to listen to students, to view the workplace through their eyes and to invite them into conversations about their perceptions and experiences.

Conclusion

Heather’s story reflects a human face behind the paradigm shifts occurring in healthcare and nursing education. Today, few Registered Nurses are interested in specializing in mental health, sweeping changes have impacted clinical practice settings and university programs now replace hospital schools of nursing. In this radically changed environment, it has become more important than ever to empathize with novices entering the profession and to understand what they find engaging and difficult about this unique clinical area. For Heather, learning psychiatric nursing centred on themes of clarifying her own personal and professional growth and discovering the need for reflective time. Students, with their fresh insights and perceptions, provide us with a mirror image of how psychiatric clinical practice environments can appear to newcomers. To ensure that this image is a positive one, it is imperative that university curricula include adequate mental health content. Furthermore, it is equally imperative for practitioners to involve and mentor students in new and creative ways.

Failing to address the current crisis of disinterest in the speciality, short-changes students as well as the educators and practitioners who are expected to facilitate their progress. By listening to the voices of learners, we may be inspired to reverse this disturbing trend. This is both a challenge and an opportunity for the field.

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