Over the past 3 years, mental health nursing faculty at an urban, state-supported university have witnessed the deterioration of mental health nursing clinical learning experiences, nursing staff disengagement from baccalaureate students, and an increasing difficulty to provide high-quality clinical learning opportunities. Problems with clinical training site availability has been reported as a contributing factor for turning away 68,938 qualified applicants to baccalaureate and graduate nursing programs in the 2014–2015 academic year (American Association of Colleges of Nursing, 2015). Students in our mental health nursing courses have reported avoidance behaviors by nursing staff and lack of access to nurses as educational resources. In turn, staff nurses described problems with crowded work spaces, uncertainty about student learning objectives, and questions about their role in student learning. A larger volume of students placed in shrinking numbers of clinical sites has resulted in critical overcrowding in mental health care settings. The overcrowding is partially due to multiple nursing programs having students on the units simultaneously. The purpose of this article is to describe and report on a layered, multiplatform engagement learning experience (PsyConnect) with students in a baccalaureate, mental health nursing course. The goals of PsyConnect were to increase student engagement, reduce inpatient overcrowding, maximize clinical learning opportunities, and improve the teaching and learning experience for students, nurses, and faculty. All evaluation was conducted in accordance with university institutional review board's human subjects guidelines.
Student engagement is a multidimensional construct that includes affective connections within the academic environment and active student participation (Christenson, Reschly, & Wylie, 2012). Best practices leading to student engagement are adequate academic challenge, active and collaborative learning, student– faculty interaction, enriching educational experiences, and supportive learning environments (Fletcher, 2015; Popkess & McDaniel, 2011). Engaged students tend to go beyond satisfaction of basic academic requirements and demonstrate persistence in learning, motivation, self-direction, and openness to challenge (Christenson et al., 2012). These students earn better grades and demonstrate increased ability to transfer skills to novel situations (McClenney, Marti, & Adkins, 2012). In a review of research findings on active learning effectiveness in nursing and health professions education, 15 of 22 studies reported positive outcomes as measured by test scores, grade point average, and student satisfaction (Waltz, Jenkins, & Han, 2014). Novice nursing students tend to prefer engaged clinical learning experiences characterized by diverse experiences, shared learning opportunities, and active learning (D'Souza, Venkatesaperumal, Radhakrishnan, & Balachandran, 2013). But despite the supportive evidence, positive outcomes, and student preferences, nursing students reported being significantly less engaged in collaborative and active learning compared with other health professions majors, according to the National Survey of Student Engagement (Popkess & McDaniel, 2011).
Traditionally, students in the mental health nursing course spent 8 hours per week in inpatient units with one clinical instructor during the 14-week semester. In an effort to reengage students in their own learning, mental health nursing faculty developed PsyConnect based on engagement learning theory (Coates, 2007, 2010). PsyConnect used three learning platforms to expand on the traditional clinical structure. First, inpatient experiences were augmented with student rotation through clinical settings across the care continuum (e.g., intensive outpatient programs, electroconvulsive therapy, mental health clinics), and with clinical checklists, which served to increase interactions among students and health care professionals in a variety of settings. Second, off-unit learning modules incorporated interactive illustrative video clips to promote group discussion, collaborative learning, and competency development. Third, simulation experiences integrated health system nurses into campus simulation exercises. Strategies for each platform were designed according to specific engagement learning concepts.
Mental health nursing is academically challenging for undergraduate nursing students because concepts are abstract and care is nuanced. Mental health care requires students to carefully monitor nonverbal communication, understand signs and symptoms within the context of intense personal narratives, and master the therapeutic use of self. These academic and psychosocial challenges prime students for acceptance of engagement learning activities. Active and collaborative learning strategies included simulation with mental health nurses, learning modules, including video clip group discussions and motivational interviewing and screening, brief intervention, and referral to treatment (SBIRT) training. All aspects of PsyConnect increased interaction among students, faculty, and care providers. Structure for these interactions was provided by the use of a clinical checklist. Clinical experiences were enriched through strategic exposure to the continuum of mental health care. Clinical setting rotations also served to decrease the number of students on inpatient units at any given time. PsyConnect supported learners by providing numerous opportunities across several settings for students to connect with faculty and others for academic or emotional assistance. Formal supportive individuals included clinical faculty, simulation facilitators, the course didactic leader, and health system nurses and administrators.
Prior to course initiation, clinical instructors were trained and provided teaching manuals, including week-by-week guides, assignments, clinical setting rotation grids, grading rubrics, and reflection questions. Lead course faculty collaborated with directors and managers of mental health services to discuss the clinical learning strategy. The students' clinical checklists included items such as patient room search, observation of a diagnostic interview, collection of a urine drug screen, attending a treatment team, and observing judicial proceedings. Students carried the checklist on their person at all times during clinical experiences and collected signatures from individuals who facilitated their learning. The instructor to student ratio was 1:8 prior to implementation. Students were assigned to one of eight inpatient facilities of varying sizes, census, and nurse–patient ratios. Students rotated through outpatient areas that were owned and operated by their assigned inpatient health system. These rotations provided for an inpatient instructor–student ratio reduction to 1:5.
Off-unit learning modules focused on students' understanding of mental health disorders and their impact on families, communities, and care systems. Students viewed video clips individually then met with faculty and five to eight other students to discuss the content. Video clips from Girl Interrupted (1999), A Beautiful Mind (2002), and A Personal Journey Into Global Mental Health (2013) were matched to didactic content. Instructors facilitated clinical reasoning exercises and discussions about disorders, ethics, global mental health perspectives, stigma, care quality, and health care reform.
Course faculty met with leaders from the largest, local mental health care system about integrating nurses into the campus simulation experiences. Health system directors, managers and nurse educators recruited nurses from a pool of their most seasoned employees. Participating nurses held at least a baccalaureate degree, and two were masters prepared. Health system nurses perceived the simulation opportunity as a privilege of seniority as nurses were compensated by the system for their time in simulation. Nurses from the primary clinical site engaged with students by acting as standard patients in scenarios of auditory hallucinations, psychotic agitation management, intimate partner violence, and environmental safety for suicidal patients. Following the scenarios, faculty and nurses comoderated simulation debriefs. Nurses were exposed to course learning objectives in action, increasing their understanding of student learning objectives and outcomes.
Eighty-two students in the second-semester, junior-year, mental health nursing course participated in PsyConnect for one academic semester. Data were collected at the end of the semester using researcher-developed surveys for students, faculty, and nurses who attended the on-campus simulation. Student surveys included demographics, nine items about checklists and inpatient learning, and two items about simulation using a 5-point Likert scale (i.e., 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree). The simulation surveys asked about learning effectiveness and outcomes.
Faculty surveys included 8 items, with a 5-point Likert response option. Similarly, faculty surveys asked about learning effectiveness in clinical and simulation. The 8-item short-answer nurse survey was administered to nurses who participated in simulation with students. Some nurses attended more than once and completed only one survey. The nurses were asked about their perceptions of the simulation experience and student learning. Systems outcomes were based on the number of students on the inpatient units and the duration of student presence on units.
Seventy-seven students (i.e., a 94% response rate), eight of eight faculty members, and four of five clinical nurses completed surveys. Results from the student surveys about use of the clinical checklist were “the checklist helped me understand unit opportunities” (mean = 4.35), “guided independent learning” (mean = 4.25), “increased my interaction with nurses” (mean = 3.81), “increased course content understanding” (mean = 4.11), “helped teach me about mental health nursing” (mean = 3.67), “guided my learning objectives” (mean = 3.63), “increased interaction with non-nursing staff” (mean = 3.88), and “increased nurses' willingness to engage” (mean = 4.00).
Eighty-eight percent of students agreed or strongly agreed that the video clips improved their understanding of stigma and family challenges related to mental illness (mean = 4.64). Eighty-one percent agreed or strongly agreed that having nurses in simulation enhanced their learning experience (mean = 4.52).
Faculty who viewed clinical checklists as beneficial to student learning also agreed that the checklist increased nursing staff engagement with students (r = .911, p = .011) and that the checklists were appreciated by the nurses on the units (r = .929, p = .007). Positive faculty attitudes about the use of clinical checklists were associated with higher survey scores among their students.
In postsimulation surveys, nurses' comments included “brings me joy to see critical thinking scenarios,” “nursing education has come a long way,” and simulation makes me “more likely” to engage with students in the clinical setting. Overall, participating nurses stated that they valued the campus simulation experiences with students and felt it increased their understanding of the student perspective and learning experience.
PsyConnect learning modules, simulated experiences, and extrinsic rotations promoted accomplishment of student learning outcomes with fewer hours spent on the inpatient units. The number of students on the clinical unit at any one time decreased from eight to five students and inpatient time decreased from 8 to 6.5 hours.
PsyConnect engagement strategies were successful in increasing students' perceptions of their ability to work independently and improved their understanding of course material, as reported by others in the literature (Christenson et al., 2012; Waltz et al., 2014). Nursing faculty agreed that PsyConnect engagement strategies improved student learning and students' relationships with nursing staff. Roorda, Koomen, Spilt, and Oort (2011) found significant associations between affective teacher–learner relationships and academic engagement and achievement. Their work highlights the importance of nursing student–staff nurse and nursing student– faculty relationships in clinical learning. Clinical checklists and simulations with nursing staff required nursing students and nursing staff to interact and engage in course content on more intimate levels, compared with traditional clinical rotations.
The layered, multiplatform learning approach provided students with rich and varied learning and interaction opportunities. Enhanced experiential variety was valued by nursing students in PsyConnect and may be an important engagement element for inclusion in nursing education (D'Souza et al., 2013). PsyConnect implementation also achieved a reduction of students on inpatient units, thereby reducing overcrowding and with no apparent negative effect on student learning. In the context of shrinking clinical learning opportunities, nursing faculty must develop innovative, engaging strategies to both enhance students' learning experiences and reduce overcrowding in inpatient units.
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