Developing communication skills and therapeutic relationships are key components in baccalaureate nursing education. These skills and techniques are emphasized within mental health courses as nursing student interactions are viewed as key interventions to foster patient coping, stabilization, and recovery. However, patients with mental illness are not an easy population to communicate with regarding their stress levels and disease processes. This situation is magnified for nursing students who are still learning ways to dialogue with mental health patients and possibly being fearful of saying the wrong thing (Happell & Gaskin, 2013).
Therapeutic communication is defined as the face-to-face process of interacting that focuses on advancing the physical and emotional well-being of a patient (Berman, Snyder, & Frandsen, 2016; Hawamdeh & Fakhry, 2013; Kleier, 2013). Therapeutic communication is a key component of most mental health curricula in undergraduate baccalaureate programs whereby nursing students are instructed on the use of communication skills to foster therapeutic relationships with patients who may be experiencing anxiety, depression, suicidal thoughts, and perceptual disturbances. Therapeutic relationships are relationships in which nurses are trusted to understand and have empathy for patients with the intentionality to support patients to recognize their own needs and gain empowerment in their lives (Farrelly & Lester, 2014). Art therapy is a recognized method of promoting mental health, encouraging patients to share fears and anxieties, as well as to cope with stressors (Leckey, 2011; Lobban, 2014; Maujean, Pepping, & Kendall, 2014).
The literature search for this study was conducted using CINAHL® and PubMed® (2006 to 2016), which revealed a paucity of research on the effects or benefits of nursing students actually using art therapy when communicating with mental health patients. In addition, although nursing students may be exposed to art therapy in the clinical setting, it is not viewed as an intentional nursing curriculum element to foster nursing communication techniques or skills. Therefore, this gap clearly indicates a justification for this study as a basis for future curriculum considerations and recommendations in holistic nursing scholarship and education.
Design and Process
This qualitative study followed the process of using focus group interviews for analysis as described by Krueger (2006). In this study, art therapy is defined as coloring or drawing. Art therapy was rendered in each clinical setting in the form of crayons and paper or coloring books. In some settings, nursing students initiated the art therapy, whereas in other settings, it was conducted under the direction of an art therapist who primarily provided suggestions for content. The content of the drawings were not included in this analysis. Nursing students and mental health patients actively participated in coloring together on a one-to-one basis in an open, observed area—such as in the dining room or in a group setting—all in a locked and secured clinical unit.
The study setting was a major university in the midwestern United States. The convenience sample was drawn from baccalaureate nursing students who had completed or were completing their mental health session (i.e., at least 4 weeks into the session). Various clinical sites were used to provide the school's mental health experiences. Two of the researchers not affiliated with the university went to the students' class to describe the study and ask for volunteers. Participants were offered a $25 gift certificate for participating in the study. Thirty-two nursing students agreed to participate in the study. Participants in the study consisted of both male and female nursing students from diverse social and ethnic backgrounds.
This study was approved by the institutional review board at the school of nursing where the first three authors are employed, and departmental approval was also given at the study site. The rights of the participants were protected by obtaining informed and written consent. Participation was strictly voluntary and had nothing to do with course grades or standing in the school. Students were told that student names, gender, and any specific identifying information would not be recorded or transcribed to ensure confidentiality. Patients were not asked to sign any consent form, as this was a retrospective study using student interviews; patients were not interviewed and no danger existed to patients.
Semistructured interviews were conducted in the form of five focus groups (6 to 8 participants per group) for approximately 1 hour. This was conducted to allow students the opportunity to reflect on their experiences of art therapy in the mental health setting; the importance of reflections in thematic analysis was described by Braun and Clarke (2006) and Nolan and Carmack (2016). Focus groups were selected as the methodology for this study because they allow for richer, thicker, and more complex levels of understanding in alignment with this study's research question, as described by Kamberelis and Dimitriadis (2011). All nursing students took turns answering the interview questions; when responding to the questions, they were assigned numbers rather than using their names. In some exchanges, student comments supported those of others. Reflective of the nature of focus groups as described by Ryan, Gandha, Culbertson and Carlson (2014), other exchanges of student comments stimulated new insights and collective viewpoints.
Three primary interview questions with probes were asked of the students during all interviews to answer the research questions:
- What is it like to communicate with mental health patients?
- Have you used art therapy when communicating with mental health patients? What was it like?
- How does art therapy assist you to communicate with your patient during your mental health experience?
Data were collected via audiotape and then analyzed and summarized into themes for reporting according to principles of thematic analysis, as described by Braun and Clarke (2006) and Nolan and Carmack (2016). The interviews were professionally transcribed verbatim, and the accuracy of the transcriptions was verified by the primary investigator (R.R.). The transcripts were read multiple times to identify commonly occurring words and ideas. These formed the basis for the analysis. Data were processed and analyzed using the Atlas.ti® 7 software program. Discrete themes were initially identified by in vivo coding of the nursing students' open-ended interview responses. Later, these codes were refined to reflect common elements and were named to capture the essential meaning of each theme. Subthemes were identified during this process. In addition, the investigator's memos, hand-written notes, and diagrams of the data were used in the data analysis. All themes were reviewed to ensure that they emerged from the data, thus avoiding a priori assumptions.
The in vivo codes and emerging themes were reviewed by the researchers, and discrepancies were resolved by examining the transcripts to ascertain the meaning of the thoughts and perceptions of the nursing students. The participants' words in the transcripts provided final support of the results derived. Findings were compared with the original transcripts, as well as the researchers' memos and diagrams. To promote credibility of the findings, a confirmatory analysis was conducted by a colleague expert, independent of the study, having a mental health clinical background and experienced in qualitative research methods.
Three key themes were identified as Nursing Students' Initial Experiences With Mental Health Patients, Nursing Students' Observations of Mental Health Patients, and Nursing Students' and Mental Health Patients' Responses to Art Therapy (Table).
Emergent Themes When Using Art Therapy
Nursing Students' Initial Experiences With Mental Health Patients
As nursing students began their mental health clinical rotation, they experienced anxiety regarding perceptions of individuals with mental illness, reactions to the mental health setting, and the nursing student role itself. Nursing students are susceptible to stereotypes of society, cultures, and media reports of mental health patients being violent and overtly sexual. This can adversely influence nursing students' initial contact with mental health patients and can make opening communication efforts reserved and awkward.
Perceptions of Participants With Mental Health Issues. Students feared that mental health patients could be unpredictable, which could include violent, aggressive, sexual, and overly emotional behavior. The students acknowledged that they shared the stigma that many in society have of mental health patients as being different, as reported by Hawamdeh and Fakhry (2014). Students repeatedly described how the stigma of mental illness was a basis for anxiety as they began interacting with mental health patients; however, this feeling changed over time. Part of the anxiety for initial interactions with mental health patients was because this was a type of patient that many of the students had never encountered:
I think a lot of that had to do with the negative stigma associated with mental health. It was interesting to go into clinical. I will admit that I was nervous the first day on the unit and interacting with patients, but the biggest thing for me was to realize and understand and fully grasp the fact that they are just like anybody else, so having a conversation after you have gotten that out of the way was a lot smoother and went a lot better than it did originally.
Reactions to the Mental Health Patients in a Locked Nursing Unit. As nursing students began their mental health clinical rotation, a common reaction was that being around mental health patients in a locked unit was “confining, scary, and unpredictable,” as one student stated. Of importance, the students had to rely on themselves as offering therapeutic conversation rather than focusing on technical skills. Many felt nervous about making a communication error with this sensitive patient group in the unit. This led to them being “hyperaware” during the conversation where they became “conscious of every single thing.” Students said these perceptions were a basis for difficulties with initial communication compared to communication outside the locked unit. This resulted in the fear of losing a patient's trust and confidence because of not saying or doing the “right thing.” Some students also reported being fearful of saying something that might spiral the patient to become aggressive, cry, or withdraw from the interaction and the student:
- I would have to say that communicating with a mental health patient is very challenging, depending on the diagnoses. It can be scary at times because you never know what kind of expressions you are going to get or what they are going to say back.
- I was just very hyperaware that something I could say could affect their treatment or affect what is going on with them and I felt like if I did not say the right things, then I would not have that trusting relationship with them and then they would not want to talk to me and the whole purpose of the nurse is to figure out what is going on with them and if I cannot communicate effectively with them. It just made me nervous that I was not doing or saying the right things because we were focusing in so much on the right things to say that when you are there in the moment having a conversation, you are trying to make it as natural as possible, but also there are some things that you would go to say and then you would think wait, I should not say that.
Nursing Students' Observations of Mental Health Patients
The nursing students made several key observations of working with mental health patients.
Mental Health Patients' Feelings. The nursing students stated that the mental health patients felt angry and stigmatized. A study by Wyder, Bland, Blythe, Matarasso, and Crompton (2015) supported this perception; mental health patients described how being hospitalized involuntarily had protected them, yet had also made them feel as though treatment was an intrusion on their liberty and physical integrity. In such a restrictive and sometimes coercive environment, mental health patients may feel disrespected, isolated, and angry.
Nursing students also reported that mental health patients were “bored.” This boredom may mirror the nature of a restrictive milieu, a locked unit, where mental health patient behaviors and responses to treatment are closely monitored. In addition, nursing students may be fearful or hesitant when interacting with mental health patients to obtain information about the patients' suicide ideation or feelings of harming themselves. Yet, nursing students must learn to assess mental health patient feelings and thoughts about suicide as a basic psychiatric assessment to be conducted at least each shift.
- I think they just bring a lot of stigma into it. They would say, “I'm in this ward because you guys think I'm crazy” or something like that.
- The major complaint that I heard from a lot of the patients is that they are bored and they do not want to be here. They are just bored.
Mental Health Patients Want Their Story Heard. In working with mental health patients, nursing students reported that mental health patients “want their story heard.” This may well reflect the nature of the therapeutic relationship whereby mental health patients want to be heard, valued, and understood (Varcolis, 2014). Of consequence, listening by nursing staff (and nursing students) is key to a therapeutic relationship with mental health patients in terms of recovery, stabilization, and community independence, as one student stated:
A lot of times, people are just sitting there by themselves and they just need someone to talk to and they do not have anybody, and they might be in for suicide because they do not have a support system.
The Mental Health Patient as an Individual. Nursing students came to recognize that mental health patients are not all the same, that mental health patients are individuals. In a study by Wyder et al. (2015), mental health patients consistently spoke about the importance of sharing their experiences with staff who focused on their individual experiences rather than on their diagnosis. Nursing students began to see patients as people and the professional relationship evolve into one of therapeutic interactions. Nursing students stated that they learned to see the mental health patient as a person and not a diagnosis:
I would have to say that really communicating with mental health individuals is really a learning experience, so what works for one patient might not work for another patient…. You really have to know what may be helpful to them to guide you in your communication.
Nursing Students' and Mental Health Patients' Responses to Art Therapy
Easier to Approach the Mental Health Patient. The art therapy session sometimes has music that is somewhat mellow and results in a decreased noise level. The therapist often has a topic and gives specific directions to meditate on through art. Students may be active participants in this therapy. At the end of the art therapy session, participants are asked to share their drawings and their perceptions. Nursing students are also allowed to discuss the meaning of the activity. In this way, art therapy provides a means of open communication for all.
Nursing students found that art therapy made it easier to approach and make initial contact with the mental health patient. Art therapy reduced nursing student and patient stress over introductions because it was a shared activity that broke down communication barriers between the nursing student and the patient. Both nursing student and patient had something other than the interaction to focus on, providing common goals and activities in a less threatening environment. One student stated:
I think there was more of a calm in the room and it almost was easier for me to approach patients when they were coloring. It was almost like we did not make complete eye contact until we were down at the same level and I sat down next to them while they were coloring and then they looked up, so it was almost like it was not confrontational or it did not feel like I was being aggressive to them.
Opens Lines of Communication. Nursing students reported that art therapy “opened lines of communication” with mental health patients beyond diagnosis. In addition, because it was viewed as a distraction from the constraints of being in a locked unit, nursing students reported that art therapy made it easier to talk not only to their patient, but also to the patients sitting nearby. Nursing students and patients actually started talking to each other when coloring.
The benefits of having shared activities with mental health patients is described in the literature. For example, Van Lith, Fenner, and Schofield (2011) suggested that play activities and positive life events improve outcomes with mental health patients through healthy socializations and accomplishments. Art therapy enabled both student and patient a comfortable silence and active (i.e., safe) ways of communicating with each other:
- Art therapy would be a good tool to open lines of communication with the patient and reduce their stress and anxiety levels. Also, if a patient is coloring, painting, or making images, you can analyze their art and ask them what does this mean, why do you draw the particular picture, if there is something they want to talk about. Does it symbolize something?
- It is an outlet for the patients. It was great for us. We could sit down and…it is a distraction tool, so they are not necessarily focused on what is going on around them or what is going on in their head. They focus on what is there and they will just openly tell you things that they probably would not have told you if you were sitting there in a room not doing anything but looking at each other or looking at the floor or the ceiling, so it is a very beneficial tool overall.
Promotes a Bond and Feelings of Trust. Nursing students stated that art therapy promoted a “bond” with mental health patients, and that it provided “common ground and a sense of openness and trust.” Art therapy placed the nursing student and patient on the same level of being, making interactions less forced and awkward. Mental health patients place importance on the student (i.e., practitioner) being able to handle the patients' emotions and feel more confident because of staff interest and emotional support (Hepworth, Rooney, Rooney, Strom-Gottfried, & Larson, 2013). Art therapy allowed nursing students to take an active interest in the patient beyond diagnosis, connecting with hopes for wellness.
Trust is a core element of the therapeutic relationship (Farrelly & Lester, 2014). Trust was established and, as observed earlier, students were aware of the importance of trust in a therapeutic relationship. Through coloring, nursing students reached out to their patients in calm, nonjudgmental, and caring ways. Mental health patients often reciprocated this interaction by trusting the nursing student with their emotions, thoughts, and feelings. A student commented:
I believe that when the [nursing student] is using art therapy with a mental health patient, it allows for focus and letting go of the problems that the person is dealing with or the constraints of the problems that the person is dealing with and it puts you on the same plane with that person because you are both involved and you both have the same amount of interest in it and then what that does is allow an avenue of trust and relativity for the person to open up to the student and speak about anything they want to speak about and usually it is about what they are there for.
Empowers the Mental Health Patient. Through art therapy, mental health patients accomplished and participated in a therapeutic activity that resulted in an improved sense of self-worth, completing a task and goals for the day. This reflects findings by Van Lith et al. (2011), who reported that art therapy released tensions in mental health patients and fostered feelings of “empowerment.” This sense of empowerment is critical for the recovery and community independence of mental health patients who may be negated and imprisoned by their illness.
Nursing students reported that art therapy reduced the stigma that mental health patients felt an improved patient self-esteem and sense of empowerment. It lifted patient spirits. Patients drew their picture and told their story, and something positive was accomplished. A student commented:
I also feel like it gives someone almost like a sense of self-worth by doing art therapy like they accomplished something and like, “I colored this and I sat down and talked to this person,” so I think it is great.
Changes in the Nursing Students. Nursing students reported that art therapy made them feel more relaxed and calm and less stressed. It gave them confidence to overcome initial fears and initiate contact and interact with mental health patients in a positive manner. Of importance, art therapy promoted conversation and ways of relating to mental health patients in safe and therapeutic ways. Art therapy fostered nursing students' professional development and communication skills. One student commented:
Conversation without art therapy, as a [nursing student], I am constantly thinking what the right thing to say is and I am just thinking so hard that sometimes I do not know what to say because I am trying to think about what I should say because I do not want to mess anything up. But when I colored with a patient while I was talking to her, it lessened my anxiety about the conversation, which I think promoted a better conversation.
Nursing students experienced a sense of professional growth with communication skills when using art therapy with mental health patients. In explaining the effects of art therapy on a therapeutic relationship and communication with mental health patients, nursing students were cautious and fearful at first. After participating in art therapy, nursing students and mental health patients formed therapeutic alliances whereby communication was possible.
Art therapy provided mental health patients with a sense of empowerment and improved self-esteem, as described by Hurley, Linsley, Rowe, and Fontanella (2014). Mental health patients took pleasure in accomplishing something through coloring. Parallel to this, nursing students gained confidence in their communication skills.
Art therapy reduced stress in both nursing students and mental health patients and improved the environment, making the locked unit a calmer place. Concurrently, mental health patients' interactions with others also improved, which fostered patient opportunities for self-expression, as described by Stickley and Hui (2012). Of importance, nursing students became comfortable with silence. Savett (2011) pointed out that deliberate silence, engaged listening, and restrained response express the presence and comfort of caregivers, allowing nurses to be focused and reflective on what the patient is saying. Art therapy enabled “a comfortable silence” between nursing students and mental health patients, where both could just be with each other in a safe and nonjudgmental relationship.
The findings from this study may not be widely transferable. The study was conducted on one campus at a school of nursing in the midwestern United States. Participants were baccalaureate nursing students, and the institution required the nursing students to have a grade point average of 3.0. Although the categories that emerged from data analysis were repeated from multiple subjects, the design of the study limited saturation, as participants were invited to participate in only one interview, which precluded the possibility of member checking. In addition, a future study using more open-ended questions is recommended to allow free expression of perceptions without the use of leading questions.