Ms. Keeley is Associate Professor, and Ms. Chase is Assistant Professor, Georgia Baptist College of Nursing, Mercer University, Atlanta, Georgia.
Presented in part as a poster at American Psychiatric Nurses Association Annual Conference, October 2008, Minneapolis, Minnesota.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Dr. Laura Kimble and Dr. Helen Hodges for their editorial support and guidance, as well as Mr. Eric Spencer, Executive Director, National Alliance on Mental Illness–Georgia (NAMI-GA), for his support of this educational activity and review of the manuscript. They also thank the NAMI-GA families for their support and participation.
Address correspondence to Ann C. Keeley, MN, RN, PMHCNS-BC, Associate Professor, Georgia Baptist College of Nursing, Mercer University, 3001 Mercer University Drive, Atlanta, GA 30341-4155; e-mail: Keeley_AC@mercer.edu.
There is general consensus that family caregivers of individuals with chronic illness may experience profound stressors (Corrigan & Miller, 2004; Horsfall, Cleary, & Hunt, 2010; Schmetzer & Lafuze, 2008). Unlike families of individuals with medical illnesses, family caregivers of individuals with mental illness must cope with multiple expressions of stigma. Although it is widely recognized that individuals with mental illness experience discrimination, family members of individuals with mental illness also experience a heavy burden of stigma that can lead to emotional distress and trauma (Corrigan & Miller, 2004). Effective nursing care of the families of individuals with mental illness requires empathy and caring, behaviors in the affective domain of learning (Marshall, Bell, & Moules, 2010; O’Connor, 2006).
Promoting learning in the affective domain is challenging, as it requires a learning situation where emotional responses are elicited and processed in a positive way (O’Connor, 2006). To address this challenge, mental health faculty from one college of nursing developed an experiential family assessment learning experience to promote affective learning for baccalaureate students in the area of nursing care for families of individuals with mental illness, particularly for family caregivers. The theoretical perspectives supporting the experience included the work of Fink (2003), an educational theorist, who emphasized that the human dimension is an important category of learning. From a nursing perspective, the learning experience is consistent with Hildegard Peplau’s Interpersonal Theory in Nursing Practice. Peplau emphasized that it is through interpersonal interactions between the nurse and individual with mental illness and his or her family that therapeutic work can be done (O’Toole & Welt, 1989). Peplau also stated that when nurses have inaccurate or preconceived ideas about a mentally ill individual’s situation, the therapeutic nature of this interaction is diminished (O’Toole & Welt, 1989). The learning experience involved partnering with the National Alliance on Mental Illness in Georgia (NAMI-GA), a grassroots advocacy organization focused on reducing stigma associated with mental illness and improving the lives of individuals with mental illness and their families. The goals of the experience were to:
- Model family assessment interview techniques with students in a participant observer role.
- Use an experiential approach to decrease stigma, change attitudes, and promote advocacy behaviors among students.
- Provide the opportunity for students to record, interpret, and analyze data to formulate realistic family-focused interventions and community-based referrals.
- Create a meaningful experience regarding family assessment for students whose primary exposure is to the client only.
- Integrate both affective and cognitive components within the experience.
- Provide guided processing of assessment data with family theory.
Mental health nursing is an essential component of undergraduate nursing curricula. Emerging trends in mental health services indicate an increasing need for nurses to be prepared to provide care for those with mental illness, as well as their family caregivers. Individuals with mental illness are increasingly being treated as outpatients, with inpatient care only for acute exacerbations (Corrigan, 2006). Because mental illness and problems with substance abuse are common, family members must negotiate complex health and legal systems to advocate for family members (Harling et al., 2006). Family-focused care for the families of individuals with mental illness requires strong communication skills and creative problem solving (Grandine, 1995). A recent study by Zauszniewski and Bekhet (2010) examined the concept of resilience in families of individuals with mental illness. Their findings proposed several interventions for advanced practice nurses, but a limitation of their work was that it did not address how these interventions might be taught within an undergraduate nursing curriculum. A primary gap in adequate preparation of mental health nurses identified by Horsfall et al. (2010) was the need for health care providers to examine their own values and beliefs. Such an examination has the potential to result in less stereotypic approaches to individuals with mental illness.
Although providing experiences with families is growing in importance, there are few structured opportunities within the nursing curriculum for students to interact with families, especially family caregivers of individuals with mental illness. In addition, providing opportunities for nursing students to intentionally interact with families in the clinical setting remains a challenge. Throughout the country, state nursing boards are approving additional nursing programs in response to the shortage of nurses. A common result of this practice is aggressive competition among schools for placements of their students in settings that will provide the best learning experience in the most efficient manner. The challenge for nurse educators is not only to “think outside the box,” but also to “move outside the box.” With limited access to mental health settings and even more limited access to the families of individuals with mental illness, moving outside the box requires faculty to proactively create learning experiences within the traditional curricula that use nontraditional methods. Mental health nursing faculty who use theory and evidence-based unique learning experiences help to promote learning outcomes in all the behavioral domains and may “ensure higher student motivation” (Nilson, 2003, p. 119).
An issue often confronted when designing learning experiences is whether they are relevant to the learner. One study of exposure of medical students to families of individuals with mental illness through a NAMI presentation concluded that this practice showed “promise for increasing communication about psychiatric disorders, treatment, and stigma issues between families and psychiatric patients” (Schmetzer & Lafuze, 2008, p. 127). This teaching strategy was developed in response to the need to provide quality experiential learning opportunities for students in the mental health nursing course.
Collaboration with NAMI-GA to Create Experiential Learning Opportunities
Collaboration between mental health nursing faculty and NAMI-GA was essential to the success of this experience. Although organizations such as NAMI have support groups, it is not feasible to assign large numbers of students to attend these groups.
Therefore, NAMI members were invited into the classroom to tell their family story, which provided an effective, value-laden experience that had the capacity to become transformative. Because of the collaboration, it was desirable that the experiential family assessment learning experience for students be congruent with NAMI’s mission to increase public education and awareness, increase advocacy, and decrease stigma. The experience was designed to provide an extension of the NAMI program, “In Our Own Voice: Living with Mental Illness,” through which consumers meet with community groups to tell their story ( http://www.nami.org). Specifically, the faculty served as the primary interviewer of a family caregiver of a person with mental illness, and students were able to ask questions. What makes this experience unique is the intentionality of the faculty related to learning in the affective domain of their students.
An experiential interview strategy was developed to model family assessment techniques and to provide students with the tools they would need to begin to effectively work with family members of individuals with mental illness. Faculty invited the NAMI-GA family member(s) to come to the class for the family interview. With this approach, a large number of students could participate simultaneously and not only benefit from the role modeling of the faculty conducting the assessment, but also from hearing the actual “story” of a family caregiver of a person with a severe and persistent mental illness. Wright and Leahey (2005) posited that “by providing a context for family members to share the illness experience, nurses allow intense emotions to be legitimized” (p. 165). Each interview was conducted with one or more family caregivers of a person with mental illness.
Coordination and Description of the Learning Experience
Family caregivers willing to tell their stories were identified at NAMI meetings or through the local NAMI affiliate from a pool of individuals who completed NAMI’s Family to Family Program. Prior to the activity, students were given information about how learning would be assessed, including criteria for a scholarly paper that would be due within 2 weeks of the interview. The grading rubric for the paper was provided so that students could organize their notes, questions, and reflections with scholarly intention and reflective examination of their experience. This formal reflective writing was subsequent to a small group discussion about the content and experience of the interview. This discussion took place in small groups (approximately seven students per group) who had been together for several weeks in the clinical setting, and it was facilitated by each group’s clinical faculty.
On the day of the experience, the family member was invited to the class for a period of 60 minutes. A mental health nursing faculty member, who was an experienced clinician, introduced the family caregiver(s) and had the primary role of conducting the interview. Interview topics were provided to family members at least 10 days prior to the interview. The primary purpose of this was to decrease anxiety, which can often come from public speaking, and allow time for family members to seek clarification as they made preparations to tell their family story in a classroom setting. The interview was not designed to be family therapy, although family members frequently reported that it was helpful for them to tell their story. Previous interviewees include parents, children, siblings, spouses, or extended family of the mentally ill individual. Family members decided who would represent the family and come to the college of nursing to be interviewed. It was not essential to the experience to have all family members present. Family members were encouraged to provide only information that they were comfortable sharing.
Nursing faculty began the interview process with a review of confidentiality with the students in the presence of the family members. The interview lasted approximately 1 hour. Students were instructed to record data and were encouraged to seek clarification and pose their own questions during and at the end of the interview. Although they were encouraged to participate in the interview process, this activity was not required because there were approximately 60 students attending each interview. The Table provides a sample of typical interview topics.
Table: Sample Interview Topics for the Experiential Family Assessment
Family Members’ Responses
A three-generational family genogram was constructed during the interview and provided information about genetic predisposition, interpersonal communication, and family system process. As the family members were interviewed, their verbal and nonverbal communication helped provide an affective context for the cognitive learning the students had already completed about mental illness. For example, prior classroom presentations had provided data about the stigma and stress that can accompany family caregivers of individuals with long-term mental illness, but the quotes provided an affective context for this knowledge. The following three quotes are examples of issues common to family caregivers, such as stress and stigma:
- I get support from telling everyone about our son. My wife is private and doesn’t discuss it with friends. We are different that way. She was mortified when I spoke about our son’s illness to her co-workers when we were out socially—work is her escape and she doesn’t want her co-workers to know. Both my wife and I are in therapy and on antidepressant [medications] to cope with our son’s illness. So I guess you might say mental illness runs in our family.
- My mother never got stable when she had to come off of lithium—she lived with me for 10 years and we were best friends even though she was very sick. I was 26 [years] old when she came to live with me. I had to find a group home when she was wandering all over the neighborhood in bad shape and I was out of town for my job. I found out after she died unexpectedly that they didn’t give her the prescribed blood pressure medication for 6 months. I guess the [medication] just fell through the cracks. She died of a cardiac event.
- One of us had to stay up all night because Tom was out in the yard and neighborhood at night trying to find the people who were after him. We were afraid he would frighten neighbors and get shot by one of them or police.
At the conclusion of the family assessment, family members were thanked for their willingness to share, often with applause from the nursing students, and were then escorted from the classroom. A follow-up letter was sent to the family members thanking them for their time and their contribution to the students’ learning. Responses from those interviewed were often expressions of gratitude for the opportunity to share their story with individuals who are future nurses.
Student Debriefing and Assessment of Learning Outcomes
After the family caregivers had left, there was an additional 30 minutes for small group work to process the effects of the interview on students’ perceptions of the day-to-day experience of this family, as well as the student’s own reactions to the interview. From a theoretical perspective, the goals of the learning experience were achieved because students gained greater insight into the experiences of the individuals with chronic mental illness and their families. In addition, students’ comments indicated that stereotypes and preconceived ideas about individuals with mental illness had been challenged. For example, one student commented, “I had no idea how stressful it is to live with a mentally ill person.” An important area of affective learning was how students could see the love and caring that family members had for the individual with mental illness in the face of all their challenges. This observation had a poignant and powerful effect on the students in that the affective experience was largely unexpected by students who may have focused only on “caregiver burden.” One student commented, “I saw a lot of love…. I did not expect such unconditional love.”
An impetus for creating this experience was the lack of opportunity for students to interact with family caregivers in more traditional psychiatric mental health clinical sites. One student commented, “We only see one dimension of patients in clinical. I can see them in multidimensional ways now.” Another stated, “I was amazed at the family dynamics…. We don’t see that in clinical.” Just as exposure to individuals with mental illness is believed to help with destigmatizing attitudes toward those individuals, this experience was designed so that exposure to those individuals’ families would also have a positive effect (Horsfall et al., 2010). One student said, “I saw how the family tried to keep it together for him…like a protective barrier to the world.”
To formally assess learning outcomes, each student developed a scholarly paper to permit faculty to assess students’ data gathering skills, interpretation of data, application of family theory, and family care planning ability. Within the structure of the paper, an affective component was included for students to reflect on their self-awareness, core values, and insights gained from interacting with the family, as well as their response to processing the experience with classmates. This portion of the paper has provided rich information to faculty about the value of the experience. Over time, the grading criteria for the affective component of the paper has been refined to elicit and evaluate desired reflective learning. The rubric includes points for identifying the “strengths and challenges” of families, “self-awareness,” and identification of the potential “effects on the student’s interactions with mentally ill patients and their families” in the future.
The experiential family assessment for families of individuals with mental illness remains an important learning activity within the undergraduate curriculum. This learning activity has been used for 6 years. Within the clinical nursing curriculum, it has been a key method for teaching and assessing learning in nursing care of the family of individuals with mental illness. As curricula change and opportunities for directed interaction with families of patients decrease, this creative experience takes on increased significance as it provides students with an opportunity to examine family theory, family development, and the effects of chronic mental illness on family members. It further allows students to potentially humanize the families and caregivers of individuals with severe and persistent mental illness. This focus is consistent with Peplau’s Interpersonal Theory of Nursing (Meleis, 2007).
A graded reflection on the effects of illness on a family’s ability to adapt, access community resources, and use the expertise of the nurse reinforces the transfer of knowledge from the classroom to the real world. Included in this process is the emphasis on the value of including the family when possible as a resource in the overall care of the individual with mental illness, and a focus that addresses the increasing call for primary prevention. Family members of a person with chronic severe mental illness are at risk for the multiple physiological, psychological, and spiritual maladies that may result from chronic stress. As a teaching–learning strategy, this experience provides potential for application across the many variations of the practice of nursing in the 21st century and a cornerstone for meeting essential components of the overall professional preparation of baccalaureate nurses.
- Corrigan, P.W. (2006). Erase the stigma: Make rehabilitation better fit people with disabilities. Rehabilitation Education, 20, 225–234.
- Corrigan, P.W. & Miller, F.E. (2004). Shame, blame, and contamination: A review of the impact of mental illness stigma on family members. Journal of Mental Health, 13, 537–548. doi:10.1080/09638230400017004 [CrossRef]
- Fink, L.D. (2003). Creating significant learning experiences: An integrated approach to designing college courses. San Francisco, CA: Jossey-Bass.
- Grandine, J. (1995). Embracing the family. The Canadian Nurse, 91(9), 31–36.
- Harling, M., Overy, C., Beckham, G., Denby, R., Goddard, S., O’Connor, C. & Tully, D., … (2006). Addressing negative attitudes toward substance use in nursing: A peer-led approach in nurse education. Drugs and Alcohol Today, 6(2), 38–41. doi:10.1108/17459265200600033 [CrossRef]
- Horsfall, J., Cleary, M. & Hunt, G.E. (2010). Stigma in mental health: Clients and professionals. Issues in Mental Health Nursing, 31, 450–455. doi:10.3109/01612840903537167 [CrossRef]
- Marshall, A., Bell, J.M. & Moules, N.J. (2010). Beliefs, suffering, and healing: A clinical practice model for families experiencing mental illness. Perspectives in Psychiatric Care46, 197–208. doi:10.1111/j.1744-6163.2010.00259.x [CrossRef]
- Meleis, A.F. (2007). Theoretical nursing: Development and progress. Philadelphia, PA: Lippincott Williams & Wilkins.
- Nilson, L.B. (2003). Teaching at its best: A research-based resource for college instructors. San Francisco, CA: Anker.
- O’Connor, T.G. (2006). Toward integrating behavioral genetics and family process. Family Systems & Health, 24, 416–424. doi:10.1037/1091-75188.8.131.526 [CrossRef]
- O’Toole, A.W. & Welt, S.R. (Eds.). (1989). Interpersonal theory in nursing practice: Selected works of Hildegard E. Peplau. New York, NY: Springer.
- Schmetzer, A.D. & Lafuze, J.E. (2008). Overcoming stigma: Involving families in medical student and psychiatric residency education. Academic Psychiatry, 32, 127–131. Retrieved from http://ap.psychiatryonline.org/article.aspx?articleID=50975 doi:10.1176/appi.ap.32.2.127 [CrossRef]
- Wright, L.M. & Leahey, M. (2005). Nurses and families: A guide to family assessment and intervention (4th ed.). Philadelphia, PA: F.A. Davis.
- Zauszniewski, J.A. & Bekhet, A.K. (2010). Resilience in family members of persons with serious mental illness. Nursing Clinics of North America, 45, 613–626. doi:10.1016/j.cnur.2010.06.007 [CrossRef]
Sample Interview Topics for the Experiential Family Assessment
|Impact of mental illness on family function|
|Positive aspects of family caregiving|
|Communication patterns in the family, including caregivers’ roles|
|Problem solving in the family|
|Community and family network of support and dis-support|
|Family financial burden|
|Experience with the legal system, health care providers, and health care facilities|
|Barriers to care related to HIPAA guidelines|
|Experience with stigma in the community and extended family|
|Insurance parity issues and access to care|
|The role NAMI plays in your life|
|A “wish list” of services not available in the community|