Dr. Webster is Assistant Professor and Associate Chair, Department of Nursing, Salisbury University, Salisbury, Maryland.
Address correspondence to Debra Webster, EdD, RN, BC, Assistant Professor and Associate Chair, Department of Nursing, Salisbury University, 1101 Camden Ave., Salisbury, MD 21801; e-mail: email@example.com.
Nursing students enter psychiatric nursing courses with assumptions, based on past experiences that are often negative and, in many cases, the result of a lack of knowledge about mental illness. The expectation that individuals with mental illness are unpredictable or dangerous is derived from what the students have been exposed to through the news media, television, and movies (O’Connor, 2006). Nursing students are challenged to face their fears and develop therapeutic nursing student-client relationships during brief psychiatric nursing clinical encounters. Any negative perception of individuals with mental illness will interfere with the development of a therapeutic relationship. Nurse educators are challenged to provide students with experiences that not only provide knowledge that addresses inaccurate negative beliefs but that also facilitate the development of an empathetic nursing student-client relationship. Although traditional teaching methods are helpful in fostering this development, creative reflective activities engage students in a process of self-reflection and examination of personal bias that changes negative attitudes and promotes empathy.
Empathy involves not only understanding a client’s feelings, it involves a level of self-awareness that allows an individual to accurately demonstrate this understanding to the client (Ulrich & Glendon, 2005). Therefore, empathy is a critical component of the therapeutic nurse-client relationship in psychiatric nursing. According to Reynolds (2000), empathy can be taught and observed. At a time during which a lot of focus is placed on the science of nursing due to the increased use of technology in health care, it is important that we do not forget the art of nursing. We must recognize that caring and empathy are essential components of the nurse-client relationship. Although it is important to focus on the science and technology to treat illness in clients, empathetic care for the individual as a human is vital. It is essential for nurse educators to discover teaching strategies that best promote the development of nursing student empathy during the psychiatric clinical experience.
Nurses with higher degrees of empathy use verbal and nonverbal communication to convey their understanding, whereas nurses with low levels of empathy are unable to interpret what the client is feeling or even disregard the client’s feelings altogether (Stuart & Laraia, 2005). The quality of treatment for those with mental illness is compromised because of the stigma associated with mental illness (Emrich, Thompson, & Moore, 2003; Halter, 2002). Negative perceptions and lack of empathy may even prohibit individuals with mental illness from seeking help (Halter, 2002). Empathy builds trust, and individuals with mental illness who perceive nurses as empathetic feel accepted and valued (Riley, 2008). Such acceptance results in increased quality of treatment for individuals with mental illness. Therefore, negative attitudes and stigma toward them must be addressed before empathy can be promoted.
Alligood (2005) defined two types of empathy—trait and state. Accordingly, trait empathy “is defined as a human development feeling attribute of the person and environment process,” and state empathy is “defined as transient behaviors enacted to convey understanding of another person” (p. 301). An understanding of differences in these concepts is needed for the selection of the best teaching strategies to facilitate nursing students’ caring for clients.
State empathy is well addressed by nurse educators; however, more focus should be placed on trait empathy based on the findings of the Empathy Research Team at the University of Tennessee (Alligood, 2005). Although traditional teaching methods, such as the process recording, focus on teaching students therapeutic communication skills, including how to respond in an empathic manner, teaching strategies that build on a student’s innate abilities are needed. Researchers on the Empathy Research Team found that “the basic trait of human developmental empathy was sustained when the behavioral state was not” (Alligood, 2005, p. 303). On the basis of this finding, they recommended that nurse educators focus on building on students’ strengths instead of teaching responses to enhance empathy.
According to Tarnow and Butcher (2005):
Some caring is innate in people, but caring provided by professional nurses needs to be taught, nurtured, and developed in students.
As a result, nurse educators should not only provide accurate knowledge about mental illness, they should use teaching methods that promote self-awareness.
Creativity and Educational Strategies
Knowledge about how to promote the growth of empathy is limited (Beddoe & Murphy, 2004). According to Armstrong and Pieranunzi (2000), the two guiding principles in psychiatric nursing education are “understanding of the illness from the patient’s point of view” and “awareness of the interplay of assumptions and biases within the therapeutic relationship” (p. 274). To effectively teach using these principles, nurse educators must consider methods to promote the application of theory that enhances caring and empathy. However, research regarding teaching methods that promote empathy in psychiatric nursing is limited. Such teaching methods should be aimed at building on innate empathy.
Idczak (2007) used a phenomenological approach to examine the way in which nursing students described their interactions with patients during a nursing fundamentals clinical course. After examining journals kept by students, Idczak concluded that empathy development was enhanced over time and that self-reflection and experience were important as students learned to provide empathetic care.
Although traditional teaching strategies such as process recordings, assessments, and care plans may be effective in teaching communication and the basic nursing process, other nontraditional teaching strategies may be more promising in the development of empathy in the therapeutic nurse-client relationship in psychiatric nursing. Robinson (2007) suggested that students are able to think creatively and their work is more culturally sensitive and empathetic when arts are a part of the curriculum. Raingruber (2004) supported this thought and suggested that poetry could be used to help students develop empathy. Olson (2002) also took a nontraditional approach in an attempt to facilitate nursing students’ ability to view clients with mental illness more holistically. He designed an assignment in which students wrote and shared poetry about their experiences in psychiatric nursing. He concluded that this assignment helped students develop an awareness of the client and insight into mental illness. McCaffrey and Purnell (2007) developed a 3-credit Arts in Healing course in which nursing students discussed how creative expression was related to client care after listening to guest speaker presentations about the use of artistic media such as poetry, music, and art. The authors concluded that the students found this course helpful in learning to be more sensitive to others.
Providing students with accurate information is an essential component in addressing stigma. Although it has been suggested that reflection is effective in facilitating empathetic care and the arts can be used to foster sensitivity, there is no research in the area of creative reflection as a teaching strategy to address stigma and promote empathy. A nontraditional teaching strategy such as creative reflection may be useful in facilitating student understanding of how negative perceptions affect empathy and interfere with the development of the therapeutic nursing student-client relationship. Through reflection, students are able to engage in self-dialogue facilitated by faculty to better understand their own feelings and biases toward individuals with mental illness. Creative expression allows students to demonstrate their understanding of the effects of mental illness on a client. According to Lowenstein and Bradshaw (2001):
Fostering creativity enhances the potential for knowledge development in the discipline because no two students are alike, and their ways of exploring phenomenon of concern to nursing will also be unique.
This study used a pretest-posttest quasi-experimental design to examine whether there were differences in nursing student empathy after a specific creative teaching strategy was implemented with some (comparison group) and not with others (control group). Empathy was measured using the Interpersonal Reactivity Index (IRI) prior to and after the clinical experience. Comparisons between the two groups were made to determine whether there were changes in empathy based on participation in a creative reflective experience in psychiatric nursing. A constructivist approach was also used to examine nursing students’ perceptions of working with individuals with mental illness and to understand the development of empathy. According to Denzin and Lincoln (1998), constructivist researchers recognize the existence of multiple realities that enable them to gain understanding of the ways in which individuals understand a phenomenon.
A demographic questionnaire provided data about age, gender, ethnicity, and education. In addition, information about previous contact with individuals with mental illness was collected.
The IRI was used to examine differences in nursing student empathy before and after the psychiatric clinical experience and to compare students in the control and comparison groups. The IRI (Davis, 1980) is a 28-item self-report tool that measures four dimensions of empathy: perspective taking, fantasy, empathic concern, and personal distress. Based on a 5-point Likert scale of responses ranging from describes me well to does not describe me well, scores for each subscale can range from 0 to 28, as each subscale has seven questions that are scored 0 through 4 points. The perspective-taking subscale measures one’s own perceived ability to adopt others’ perspectives in real-life situations, with higher scores suggesting better interpersonal functioning (Davis, 1983). The fantasy subscale measures tendencies toward identification with fictional characters with higher scores, suggesting a tendency to be helpful to others. Higher scores on the empathic concern subscale indicate an ability to feel warmth, compassion, and concern for others. Finally, the personal distress sub-scale indicates to what extent participants experience feelings of fear, anxiety, and discomfort when witnessing the distress of someone else. High scores on this subscale indicate poor interpersonal functioning. Internal reliability for this inventory was reported as 0.71 to 0.77, and test-retest reliability was reported as 0.62 to 0.71 (Davis, 1983).
A convenience sample of 73 senior baccalaureate nursing students enrolled in a psychiatric clinical course during fall 2007 voluntarily participated in the study. All students had inpatient-focused and outpatient-focused psychiatric nursing experience in a variety of settings for 14 weeks. The comparison group of 29 students had 10 weeks of traditional, inpatient-focused experiences, as well as an assignment to a community-based psychosocial rehabilitation program serving clients with mental illness for 4 weeks. During these 4 weeks, they participated in the creative reflective experience. The control group of 44 students had 10 weeks of traditional inpatient-focused experience plus 4 weeks of community-based experience in either a psychosocial rehabilitation program or a homeless shelter. This group had traditional teaching methods for the entire 14 weeks. The uneven assignment to the control and comparison groups was due to clinical space availability within the community psychosocial rehabilitation setting. Sample size adequacy was determined by a post hoc power analysis.
Participants ranged in age from 20 to 49, with the majority between the ages of 20 and 22 (72.6%). The sample was made up of 68 Caucasian students (93.1%), four African American students (5.5%), and one Asian student (1.4%). The majority of participants were women (90.4%). In addition, second-degree students comprised 21.9% (n = 16) of the sample and traditional students comprised 78.1% (n = 57). One student withdrew from the program prior to the end of the study due to medical issues. Although there were only 6 students (8.2%) with work-related psychiatric experience, 32 students (43.8%) reported having a relative with mental illness and 14 students (19.2%) reported having a friend with mental illness. A breakdown of the characteristics of students in the control and comparison groups can be found in Table 1.
Table 1: Sample Characteristics
Students were voluntarily recruited from those enrolled in the psychiatric clinical course. Permission to conduct the research study was granted by the University’s Human Subjects Research Committee. A disclosure statement was provided, informing participants of the purpose of the study, and informed consent was obtained. All participants completed the demographic questionnaire and IRI at the beginning of the clinical experience. All students who participated in the study completed conventional assignments including process recordings, assessments, care plans, and group teaching projects. At the end of the 14-week clinical experience, participants in both groups completed the IRI.
Data were collected from several sources including interviews, field observation, and student creative reflective assignments in the qualitative portion of this study. This data triangulation helped to ensure credibility (Gay, Mills, & Airasian, 2006). Using predetermined open-ended questions, semistructured interviews were conducted at the end of the clinical experience with 14 participants, selected via purposive sampling from the comparison group. This allowed the researcher to examine perceptions of both male and female participants and traditional and second-degree participants, as well as participants from each of the represented ethnic groups. Interviews lasting 45 to 60 minutes were audiorecorded and were conducted in a private meeting room in which confidentiality was assured. Weekly field notes included observation about the verbal and nonverbal interactions students had with clients with mental illness. Reflective student journals were reviewed to examine how underlying assumptions and meanings were related to student empathy development and to determine student perceptions of working with clients with mental illness.
The Creative Reflective Assignment
Students in the comparison group completed the creative reflective assignment, which consisted of two parts: a reflective journal and a creative project. This assignment was designed to encourage expression of student understanding of how mental illness affects clients. Each student conducted an assessment of the client and determined the effects that mental illness had on the client and the client’s family by holistically examining issues for the client, taking into consideration psychological, physical, spiritual, social, intellectual, sexual, and economic factors. In addition, the assignment was designed to encourage students to reflect on underlying assumptions that may affect the development of a therapeutic relationship as they worked with the client. As students reflected on significant meanings, they were asked to consider issues of bias, fear, discrimination, stigma, and culture to determine how such issues may affect empathy and the development of the therapeutic nursing student-client relationship. Students were asked to “get a feeling” of how mental illness had affected the life of the client. After working with the client for 4 weeks, students were asked to find some way to creatively depict and express this feeling so that it could be presented. Students represented the effects of mental illness on their client after reflecting on the ways in which assumptions affect individuals with mental illness and synthesizing knowledge gained from directly working with the client, talking with staff, and reviewing the client’s chart. The creative media chosen to depict these effects was left entirely up to each student.
Data were analyzed using SPSS version 15.0 software. Mean scores were computed for each subscale on the pre-test and the posttest for all participants in the sample (N = 72) and were compared using a t test for dependent samples. Although there were no statistically significant differences in empathy after the psychiatric nursing clinical experience for students in either the control or comparison group, trends were noted in scores for the perspective-taking and personal distress subscales. Students in both groups had scores that demonstrated improvement in interpersonal functioning (Table 2).
Table 2: Comparison and Control Groups Pretest-Posttest Differences After Clinical Instruction in Psychiatric Nursing
Qualitative methods were used to further explore students’ perceptions of mental illness and to gain an understanding of how students related to individuals with mental illness. Projects were analyzed and journals were reviewed to examine how underlying assumptions and meanings related to student empathy development. Students were interviewed to examine their initial reactions to working with clients with mental illness and to examine perceptions as they gained experience working with them throughout the semester. To help ensure data credibility, peer debriefings and member checks were used (Gay et al., 2006). Constant comparative method with descriptive and interpretative coding was used to analyze the data (Denzin & Lincoln, 1998). Four general themes were discovered that provided some insight into nursing students’ perceptions of mental illness and the development of empathy:
- Having expectations.
- Building relationships.
- Changing perceptions.
- Gaining understanding through creative expression.
At the beginning of the clinical experience, many of the students described a feeling of not knowing what to expect. These expectations were based on past experiences and feelings of discomfort. Initial journal reflections revealed that students were not able to demonstrate empathy for the client. Instead they were consumed with feelings of fear, anxiety, and apprehension. One student reflected, “I was unsure about everything including what I was supposed to do and say. I was unsure what to expect and how I was supposed to respond to situations.” Another reflected, “I didn’t want to do anything that might upset them, I was afraid.” Other students discussed their expectations in terms of what they had seen in the media. One student stated, “I was ready for combativeness and out of control behavior.” Another reflected, “I expected to see individuals out of touch and unable to hold a conversation.” As students worked with the same client over a 4-week period, they were able to identify that their anxiety was a result of a lack of accurate knowledge about mental illness. Reflections suggested that once anxiety decreased, focus shifted from the student to the client. One student wrote:
This was a good experience. I never realized I had placed a stigma on [people with mental illness] but after realizing how nervous I was getting about having to talk to my client and thought about why I was nervous, I realized it was for unfounded reasons.
Relationship building began immediately after students were introduced to the clients. However, empathy was only demonstrated after the initial level of discomfort was acknowledged and anxiety began to decrease. After students were able to stop focusing on their own concern for safety and were able to focus on the clients as people with needs, empathy for the clients was demonstrated and the therapeutic relationship developed. During this period of relationship development, the students gained an understanding of the clients’ disease processes and began identifying what it was like for the clients to live with mental illness. Students reported that working with the same client over a 4-week period facilitated this process. One student wrote, “I understand them a little better because I know it is difficult for them.” Another reflected on her experience in terms of being “more understanding,” stating “I think about [the client] as a person, not like this crazy person, but a real person with real feelings and real problems.” Most students commented that they looked forward to working with the same client each week to build a therapeutic relationship. They discussed that this was something they were not able to do in other psychiatric clinical settings.
Self-reflection appeared to be an important factor as each student examined his or her own perception of mental illness. In an interview, one student discussed the importance of self-reflection and stated, “Clients will not even bother to...try to open up to someone if they think they already have perceived ideas about them.” Other students reflected on ways in which their perceptions had changed and were able to discuss the need for changing the attitudes that others have toward individuals with mental illness. One student reflected, “Education and contact definitely make a difference.” Students acknowledged they had negative perceptions that had been changed through accurate information and contact with individuals with mental illness. A student who had initially reflected that she once thought individuals with mental illness “had control of their behavior and could change if they wanted” now expressed that she “saw hope that [individuals with mental illness] could be proactive in addressing their illness.” One student reflected, “A lot of the assumptions I had about [psychiatric] nursing and [psychiatric] patients have been changed through this clinical.” Another student indicated, “I had an opinion of my client at the first day and by the end it was a different opinion of him.” This student indicated that the creative reflective learning experience was positive: “You get to see them grow. You learn about yourself. You learn about them.” Another student stated, “The experience changed my perspective showing that they can be stable and they can be normal and pretty much live a normal life out in the community.” This student further suggested, “I think that if people would look at their own biases and get a different perspective, they would have a better understanding and it would benefit [patients with mental illness].” Another student summed up her experience stating, “I had stereotypical ideas about [people with mental illness] and how they would be acting. I could not have been more wrong in my perceptions.”
Gaining Understanding Through Creative Expression
It was through the creative project that the nursing students articulated and demonstrated their understanding of the life of clients with mental illness. Many of the students identified feelings of powerlessness, of being trapped, or of being out of control as a part of the clients’ struggle with mental illness. Also identified were the multiple losses (e.g., family, friends, independence) as well as the loneliness and stigma experienced by the clients as a result of living with an illness that is misunderstood by others. By sharing creative projects with each other, each student developed a deeper sense of understanding. This was articulated by students during interviews. One student commented, “The projects really made me think about what it is like for the clients and the importance of getting to know people before judging them.” Also, the weekly journal reflections related to introspection about their assumptions and biases provided another vehicle for developing a deeper understanding of self and client. One student commented, “Not only did I learn about mental illness and all of the clients, I learned a lot about myself.” As one student discussed how the creative reflective experience had the greatest influence for her, she talked in detail about her client: “It really made me see how [those with mental illness] are trapped in this disease and they can do things to lessen it, but in reality it’s never gone.” One student made a collage to show her client’s life with mental illness. She explained this collage contained images of empty rooms “to represent the loneliness and emptiness that she felt after being diagnosed and hospitalized with a mental illness.” Another student used a fish bowl and titled her project “Swimming like fish in a fish bowl with nowhere to go.” She used her project to show her client’s current situation and future goals with the items inside of the bowl representing his present situation, stating “Inside the bowl is his life now. He feels trapped in a vicious cycle swimming around and around and seeing no way out.” Through poetry, another student wrote, “I show my understanding of his suffering, his relationship with friends and family, and how he copes with the painful reality of not being like other individuals his age.”
Although the quantitative findings revealed no statistically significant differences in empathy levels, it is important to note that students in this sample had high levels of empathy prior to any instruction in psychiatric nursing, according to the IRI. It is possible that 4 weeks was not a long enough period to see any statistically significant change. It is also possible that the IRI was not as appropriate for measuring feelings of empathy toward individuals with mental illness as it would be for individuals without mental illness. Thus, consideration must be given to the fact that a tool that measured attitudes toward individuals with mental illness might better provide an indication of changes that promote empathy development in the nursing student-client relationship in psychiatric nursing courses. Although Davis (1983) suggested that cognitive empathy could be measured by the perspective-taking and fantasy subscales and affective empathy could be measured by the empathic concern and personal distress subscales, according to O’Connor (2006), empathy is affective and difficult to measure. Therefore, it may be important to find tools that measure empathy toward individuals with mental illness to determine the effects of teaching strategies on empathy development in psychiatric nursing. Caring and empathy are essential components of the nurse-client relationship; thus, it is essential that empathy be nurtured and developed to ensure quality care for clients with mental illness. On the basis of student responses, it is clear that students became more aware of how their beliefs influenced their behavior and affected the therapeutic relationship. Over time, attitudes changed and students became more willing to help clients. As fear and anxiety decreased and students gained knowledge about mental illness, empathy and caring were noted.
Providing an opportunity for students to work with the same client over an extended period helped students to develop and engage in a therapeutic relationship with clients with mental illness. As students worked with their assigned clients, they were able to reflect on their assumptions to explore the ways in which their perceptions of individuals with mental illness had changed as a result of working directly with them. This reflective process, along with accurate knowledge about mental illness and contact with individuals with mental illness, was an important component in changing negative perceptions about individuals with mental illness. These findings support the work of Idczak (2007), who concluded that empathy development is enhanced over time and that self-reflection and experience are important in the process of learning to provide empathetic care for others.
Students used poetry, diaries, drawings, paintings, mobiles, papier-mâché, haiku, shadow boxes, and other creative mediums to express themselves and demonstrate an understanding of the daily struggle that individuals with mental illness face due to the effects of mental illness and the stigmatizing beliefs of others. As suggested by Alligood (2005), it is better to use affective teaching strategies to build on students’ innate empathy as trait empathy is sustained over time. Having to create a project designed to address the affective domain of learning influenced the ways in which the students cared for and interacted with clients. Tarnow and Butcher (2005) posited the importance of developing caring in our students. All students articulated that their participation in the creative reflective activity helped them to be more sensitive to their client’s needs. Through projects, students demonstrated understanding of the complexity of mental illness as they creatively depicted the client’s attempts to live in the community and the likelihood of rehospitalization as a result of relapse due to the chronicity of their mental illness. Clients’ feelings of helplessness were depicted in the projects, and those who explored the effects of mental illness for the client’s family also captured a feeling of helplessness on the part of the family.
As students shared their creative projects with each other, they were able to see and hear numerous images and words to describe the client’s world of mental illness. This led to further discussion of the effects of mental illness on the individual. Positive change was noted in students’ attitudes toward individuals with mental illness, supporting the research of Emrich et al. (2003). Nursing students’ perceptions of mental illness were best understood through the collection and analysis of qualitative means. This supports the work of Halter (2002), who suggested that the phenomena that psychiatric nurses encounter daily in caring for clients with mental illness may be best studied using qualitative methods.
There are limitations related to the sample. The participants for the study were not randomly selected but were, in essence, a convenience sample. Although there were comparison and control groups, the assignment to these groups was not randomized by the researcher. Instead, student assignment was based on course registration and clinical space, resulting in an unequal number of students in the control and comparison groups. The ability to apply the findings of this study to other populations may be limited by the fact that, in addition to a small sample size, the majority of participants in this study were young Caucasian women. However, for the qualitative portion of the study, a purposive sample was strategically selected to include older students, men, and students representative of all of the ethnic groups in this class in addition to the young Caucasian female students.
Additional research on the patients’ perception of empathy may help provide insight into how to better facilitate the therapeutic relationship and improve care for individuals with mental illness. Continued research in empathy, its development, and its expression is needed. Not only will the outcomes of such research have an effect on attitudes, it will also help educators develop teaching strategies to foster empathy toward individuals with mental illness.
Although Davis (1983) used the IRI to measure empathy in college-age students who were enrolled in an introductory psychology course, the IRI is not specifically designed to measure empathy toward individuals with mental illness. A tool designed to explore attitudes and stigmatizing beliefs toward individuals with mental illness is needed.
Empathy, as an important aspect of providing care, is especially important when caring for individuals with mental illness. Nurse educators who are interested in finding creative and innovative educational strategies for fostering empathy in nursing students may do well to consider alternative approaches. The knowledge gained from this study suggests that a creative reflective experience reduces stigma, creates positive change in attitudes toward mental illness, facilitates the development of the nursing student-client relationship, and promotes empathy. The results of this study may help nurse educators better understand how nursing students’ perceptions of mental illness affect their learning and empathy development. This may help nurse educators plan teaching strategies in psychiatric nursing that promote empathy.
- Alligood, M.R. (2005). Rethinking empathy in nursing education: Shifting to a developmental view. In Oermann, M.H. (Ed.), Annual review of nursing education volume 3, 2005: Strategies for teaching, assessment, and program planning (pp. 299–309). New York: Springer.
- Armstrong, M.A. & Pieranunzi, V. (2000). Interpretative approaches to teaching/learning in the psychiatric/mental health practicum. Journal of Nursing Education, 39, 274–277.
- Beddoe, A.E. & Murphy, S.O. (2004). Does mindfulness decrease stress and foster empathy among nursing students?Journal of Nursing Education, 43, 305–312.
- Davis, M.H. (1980). A multidimensional approach to individual differences in empathy. JSAS Catalogue of Selected Documents in Psychology, 10, 85.
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- Gay, L.R., Mills, G.E. & Airasian, P. (2006). Educational research: Competencies for analysis and application (8th ed). Upper Saddle River, NJ: Pearson Education.
- Halter, M.J. (2002). Stigma in psychiatric nursing. Perspectives in Psychiatric Care, 38(1), 23–29.
- Idczak, S.E. (2007). I am a nurse: Nursing students learn the art and science of nursing. Nursing Education Perspectives, 28, 66–71.
- Lowenstein, A.J. & Bradshaw, M.J. (2001). Fuszard’s innovative teaching strategies in nursing (3rd ed). Sudbury, MA: Jones and Bartlett.
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- O’Connor, A.B. (2006). Clinical instruction and evaluation: A teaching resource (2nd ed.). Sudbury, MA: Jones and Bartlett.
- Olson, T. (2002). Poems, patients, and psychosocial nursing. Journal of Psychosocial Nursing & Mental Health Services, 40(2), 46–51.
- Raingruber, B. (2004). Using poetry to discover and share significant meanings in child and adolescent mental health nursing. Journal of Child and Adolescent Psychiatric Nursing, 17(1), 13–20. doi:10.1111/j.1744-6171.2004.00013.x [CrossRef]
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|Variable||Total (N= 73)||Comparison (n= 29)||Control (n= 44)|
| 20 to 22||53 (72.6%)||17 (58.6%)||36 (81.8%)|
| 23 to 25||7 (9.6%)||4 (13.8%)||3 (6.8%)|
| 26 to 28||5 (6.8%)||3 (10.3%)||2 (4.5%)|
| 29 to 31||3 (4.1%)||2 (6.9%)||1 (2.3%)|
| 32 to 34||2 (2.7%)||1 (3.4%)||1 (2.3%)|
| 35 to 37||1 (1.4%)||0 (0%)||1 (2.3%)|
| 38 to 40||0 (0%)||0 (0%)||0 (0%)|
| 41 to 43||1 (1.4%)||1 (3.4%)||0 (0%)|
| 44 and older||1 (1.4%)||1 (3.4%)||0 (0%)|
| Caucasian||68 (93.1%)||27 (93.1%)||41 (93.2%)|
| African American||4 (5.5%)||1 (3.4%)||3 (6.8%)|
| Asian||1 (1.4%)||1 (3.4%)||0 (0%)|
| Male||7 (9.6%)||3 (10.3%)||4 (9.1%)|
| Female||66 (90.4%)||26 (89.7%)||40 (90.9%)|
| Traditional||57 (78.1%)||19 (65.5%)||38 (86.4%)|
| Second-degree||16 (21.9%)||10 (34.5%)||6 (13.6%)|
|Work experience with individuals with mental illness|
| Yes||6 (8.2%)||3 (10.3%)||3 (6.8%)|
| No||67 (91.8%)||26 (89.7%)||41 (93.2%)|
|Relative with mental illness|
| Yes||32 (43.8%)||11 (37.9%)||21 (47.7%)|
| No||41 (56.2%)||18 (62.1%)||23 (52.3%)|
|Friend with mental illness|
| Yes||14 (19.2%)||9 (31%)||5 (11.4%)|
| No||59 (80.8%)||20 (69%)||39 (88.6%)|
Comparison and Control Groups Pretest-Posttest Differences After Clinical Instruction in Psychiatric Nursing
|Subscale||Comparison (n= 29)||Control (n= 43)|