Engagement in clinical placements is a mandatory aspect of all pre-registration nursing programs (Midgley, 2006). The value of learning in clinical placements is to develop real world skills for students' future careers and professions (Callaghan, Cooper, & Gray, 2007).
Although clinical placements can be a productive and educationally valuable experience, recent literature illustrates that placements within a mental health setting can vary in their educational development (Happell, Gaskin, Byrne, Welch, & Gellion, 2015). Carrigan (2012) indicated that major factors associated with ineffective placements are inadequate supervision, financial concerns, and limited space. Most mental health clinical placements adopt a medical model that provides limited insight into a recovery-oriented approach (Forber, DiGiacomo, Davidson, Carter, & Jackson, 2015). Further, clinical placements have been identified as hugely influential with regard to students' attitudes toward, and intentions to pursue, mental health nursing as a career (Mullen & Murray, 2002; Surgenor, Dunn, & Horn, 2005).
Happell et al. (2015) suggest research is needed to examine diverse and different forms of clinical placements that assist in the effective development of pre-registration nurses in the field of mental health. As a means for addressing the aforementioned concerns and need for quality clinical placements, academics at the University of Wollongong designed and implemented a clinical placement called Recovery Camp (Moxham, Liersch-Sumskis, Taylor, Patterson, & Brighton, 2015). Initial evidence has demonstrated that engagement in Recovery Camp can facilitate significantly better educational outcomes for pre-registration nurses compared with other clinical placements (Moxham, Liersch-Sumskis, et al., 2015). Although the initial evidence on Recovery Camp is positive and demonstrates promise, more evidence and research on quality clinical placements is needed.
Overview and Literature
Recovery Camp is an innovative re-conceptualization of mandatory mental health workplace experience, occurring over 5 days at an established outdoor education recreation facility in New South Wales, Australia. Underpinned by the theoretical principles of therapeutic recreation, Recovery Camp involves immersion of individuals and groups in a unique setting, offering challenging and rejuvenating activities to enhance nursing student learning and consumer involvement (Moxham, Liersch-Sumskis, et al., 2015).
Recovery Camp contributes 80 hours of workplace experience, as identified by the governing institution, for each attending pre-registration nursing student. They are joined by a multidisciplinary mix of health students (e.g., psychology, dietetics, exercise physiology), academics, and individuals with serious and enduring mental health issues (i.e., consumers). The learning experience is designed to challenge students' pre-conceptions of individuals with mental illness and mental health care, and teaches them strategies and techniques for providing recovery-oriented care. This experience is achieved through joint participation in a wide array of purpose-designed activities, ranging from physically demanding to restorative (e.g., rock climbing, Tai Chi, arts and crafts, swings, health education sessions), and conducted by trained therapeutic recreation specialists. In addition, recent research by Brighton et al. (2016) has demonstrated that the benefits of Recovery Camp extend to consumers' carers who experience respite from their caring duties. This respite assists in diminishing the negative health effects associated with caring responsibilities.
From the perspective of nursing students, research to date has illustrated that Recovery Camp highlighted the importance of multidisciplinary and interprofessional practice (Moxham, Patterson, et al., 2016). Participation in Recovery Camp led nursing students to report significant decreases in stigma toward individuals with mental illness over time, relative to a group of nursing students who attended a typical mental health clinical placement (Moxham, Taylor, et al., 2016). Recovery Camp attendance also boosted measures of nursing students' clinical confidence with regard to mental health nursing (Cowley et al., 2016; Moxham, Pegg, et al., 2015). Although the aforementioned research illustrates the potential educational benefit for pre-registration nurses, these studies adopted a quantitative approach to examine change facilitated by engagement in Recovery Camp. Patterson et al. (2016) conducted the first qualitative study and found that pre-registration nurses identified that Recovery Camp facilitated elements of professional learning. Specifically, findings suggested that students learned about professional dispositions, achieved difficult professional competencies, and understood more about therapeutic relationships. Although the results have demonstrated initial promise for engagement in Recovery Camp, more research is needed. The study by Patterson et al. (2016) found that students identified learning around the concept of therapeutic relationships, but this was a more general theme. An understanding of what elements of and how therapeutic relationships are developed could benefit the overall nurse education community. In addition, use of only one data source (reflective journals) could be viewed as a limitation. Therefore, the aim of the current study was to further examine the potential learning benefit (i.e., therapeutic relationships) of pre-registration nurses in Recovery Camp.
Ethical approval was granted by the university's Human Research Ethics Board. All participants provided their informed consent in writing. A case study approach was used (Merriam, 1998), whereby 20 pre-registration nurses in Recovery Camp were deemed the case. Qualitative data were collected ongoing at the beginning, during, and 1 week after Recovery Camp. Data were collected using individual and focus group interviews, reflective journals, and researcher field notes.
Participants were 20 pre-registration nurses in their third year of a Bachelor of Nursing undergraduate degree from an accredited Australian university. All participants in Recovery Camp included pre-registration nurses (n = 20), individuals with mental illness (n = 27), mental health nursing academics (n = 3), an educational specialist (n = 1), and a therapeutic recreation academic (n = 1).
Recovery Camp was developed as a collaborative therapeutic recreation program in which individuals with mental illness, pre-registration nursing students, and support staff (e.g., university academics) engaged in a 5-day recreation camp near Sydney, Australia. Recovery Camp employs a strengths-based, person-centered philosophy that focuses on the personal recovery of individuals with mental illness. Recovery Camp provides an additional placement setting (addressing the limited space issue for university clinical placement) and is supported by internal and external grant funds (addressing the financial concern).
Recovery Camp is an accredited mental health clinical placement, grounded in the principles of therapeutic recreation. Students who participated in Recovery Camp were provided opportunities to develop their ability to impart professional and therapeutic strategies for consumers. Their competencies were measured via the Nursing Competency Assessment Schedule (NCAS), which complies with the code of practice–student professional practice policy (Crookes et al., 2010). The NCAS requires nursing students to identify learning outcomes and objectives during their clinical placement, and meet with facilitators to discuss strengths, weaknesses, and opportunities for growth (Crookes et al., 2010). The NCAS also lists expectations for student learning, which must be reflected on during and following clinical placement.
At information sessions prior to Recovery Camp attendance, consumers were advised that students would be attending the experience as a clinical placement to develop their professional skills (e.g., therapeutic relationship building), and that they could share their experiences of mental health care. Likewise, students were advised that they could learn directly from consumers and develop therapeutic relationships while maintaining personal boundaries, which aligns with Recovery Camp's recovery-oriented, person-centered approach. Students were also advised that they could discuss any issues with their facilitator.
Pre-registration nursing student data were obtained through individual and focus group interviews, reflective journals, and researcher observations/field notes. Each nursing student was interviewed individually twice (15 to 20 minutes per interview) and once in a focus group (20 minutes). All interviews were audiorecorded for transcription. To ensure a level of consistency, only one researcher (D.P.) conducted all interviews. Each pre-registration nurse was required to complete a set of six reflections during and after Recovery Camp. The intent of the journal was to allow participants time to think and reflect on their experiences in Recovery Camp and how they influenced the development of their professional skills and abilities. During Recovery Camp, the lead researcher (D.P.) collected field notes that were used to identify behaviors, actions, and experiences that aligned with the professional learning of students and elements of the clinical placement.
Triangulation and peer debriefing (Creswell, 1998) were used to ensure a level of trustworthiness. Triangulation was achieved through the use and cross-checking of findings across all three data collection measures. A peer debriefer was used to check and support that all data, themes, and findings were accurate and represented appropriately.
Data were transcribed and analyzed using a combined inductive thematic approach (Boyatzis, 1998; Howitt & Cramer, 2007). Each data source was initially open coded by the lead researcher. Open coding provided a list of codes, code description, and supportive data sets/statements for each measure (e.g., interview, reflective journals). Codes were compared within and across each measure to provide more representative codes. This process was continued until two members of the research team (D.P., E.T.) came to an agreement on the emerging themes.
Five themes emerged from data analysis: (a) Initial Anxiety/Nervousness, (b) Diffusion of Power, (c) Student Perceptions of Consumers, (d) Interaction and Communication, and (e) Resource Shift as a Result of Camp. The Table displays field notes according to each theme.
Field Notes Taken According to Theme
The theme Initial Anxiety/Nervousness focuses on how students were being immersed in a relatively new and unknown experience compared with their previous clinical placements. Specifically, the unknown elements that facilitated a sense of anxiety within this placement were aligned with (a) lack of consumer information and (b) awareness of support by staff and nurses.
One student mentioned he/she was “nervous because we didn't know what the [consumer] diagnosis was.” Another student added, “Typically we are given information about the people we will be working with before we see them.” A third student explained:
I know this was a placement [for our degree] but I have never felt so anxious and nervous…because I didn't know what to really expect...maybe because we didn't have a designated supervising nurse or someone as a designated leader…. There were support people there but not one given as mine.
Diffusion of Power
The theme Diffusion of Power focused on how the traditional hierarchy between the health care professional and consumer diminished in the Recovery Camp setting. Literature in the nursing field has identified a clear power dynamic between individuals placed in an authoritative position (e.g., nurses) and consumers who are in more of a follower position (Milton, 2009). Students in Recovery Camp indicated that the aforementioned power dynamic was alleviated during this experience and reported that they believed everyone involved in Recovery Camp was on the same level, with one mentioning, “I feel different when working with everyone in our group. It doesn't feel like there is a split between the students and consumers.” Another student added, “A consumer I was talking with told me he felt more comfortable to talk with me and even others in the group…unlike any experience he has been with when working with people in nursing.”
Students and consumers engaged in the same activities and were required to work in a collaborative group without a clear designation of who should or would be placed in a leadership or authoritative position.
Student Perceptions of Consumers
Student perceptions of consumers as an educational resource focused on how students' ideas and thoughts about an individual with mental illness developed throughout Recovery Camp. Initially, many students developed their perceptions based on previous clinical placements and experiences in which the consumer was primarily viewed as an individual who had one or more diagnoses that needed to be treated. One student noted, “In other settings, you get a set or list of the diagnosed illness and you start to begin to think about how to address each…even before you meet the person.” Another student said:
I have to admit that when camp started I expected that the consumers would be very different…. I know this sounds bad, but not as normal as someone that doesn't have a mental illness. Not very proud of that perception as I am going to become a nurse.
As Recovery Camp continued, it was evident through observation and student statements that consumers began to feel comfortable and open up with students, and students' ideas and thoughts about consumers began to change. One student explained, “It is nice to have a regular chat and it seems like we are more friends and not having a patient–consumer relationship.” Another student added, “My biases were thrown on their head during camp…. This group of consumers is nothing like what I expected.”
Interaction and Communication
Throughout Recovery Camp, students reported that they had grown and developed in their abilities to interact and communicate with consumers in a more meaningful and appropriate manner, with one saying, “We tend to [in other settings] take on a commanding style telling the consumer what they need to do and how they need to do it.” Another student explained, “This is nothing like my last placement…. I would just tell the consumer what to do…and that was how my nurse [supervisor] did it also.”
Communication and interactions became a critical element identified by students, as Recovery Camp changed the way pre-registration nurses spoke with consumers, as well as how they would interact with consumers in a more traditional setting. One student explained, “I am just speaking to everyone [students and consumers] as if they were my friends…. I guess you could say I am treating everyone how I would like to be treated.” Another student noted, “I feel guilty because I have seen others and myself included speak to consumers in a clinical setting that was…not very personable.”
Students illustrated that they could take what they learned at Recovery Camp and translate that into other settings, such as inpatient care, with one student claiming, “I would try and speak to consumers in a more caring way anytime I would be at work…. Doesn't matter what the setting is.”
Resource Shift as a Result of Camp
Resource shift was defined as a change in which students gain information to develop their nursing skills. A resource shift emerged as many students believed that, in traditional settings, information gathering occurred through the experience of working in a placement guided by a supervising figure (e.g., a nurse). One student explained, “This setting was different because in my previous experiences I felt like a shadow. I just did what my nurse [supervisor] did or told me to do.”
It is important to note that five students used the term “shadow” as a means of explaining their role in previous placements. Although the supervising nurse was the main resource of information, engagement in Recovery Camp changed students' views of the nurses, consumers, and other students. Each became a point of gathering relevant and important information. One student noted, “I could draw so much information from both the nursing staff and consumers.” Another student added, “You are allowed to gain so much information and knowledge from not only the staff, but the consumers as well.”
Key findings support the value of an experience like Recovery Camp toward the educational development of future health professionals. It was evident that the cohort of undergraduate students developed their professional skills to build rapport and enhance their overall knowledge within the area of mental health care. First and foremost, rapport building and developing skills aligned with therapeutic relationships can be viewed as a cornerstone of providing quality care (Dziopa & Ahern, 2008; Ross, 2013). These important elements of relationship building are not often easily developed in more traditional clinical settings (Warne et al., 2010).
A theme of Initial Anxiety and Nervousness was evident, particularly with relation to students not receiving information about consumers prior to Recovery Camp. The lack of knowledge about each consumer seemed to align with the creation of an educational environment focused on understanding more about the consumer beyond their symptoms or diagnosis of mental illness. Providing a setting in which undergraduate students are uninformed is likely not a feasible option in a traditional clinical setting, but it was possible in this setting due to the support network of nurses and staff that engaged in and oversaw Recovery Camp. Spencer-Oatey (2005) suggests that an effective means for the development of rapport is to have undergraduate students engage directly with their potential clientele. Direct contact in a clinical setting is diminished due to the mediator of the supervising nurse and the time restriction of providing medical decisions (Manojlovich, 2007).
Diffusion of Power also arose as a theme. Indeed, power plays an integral role within the health care and nursing field (Manojlovich, 2007). Traditionally, nursing and medical staff are provided a high degree of power over consumers in their care (Henderson, 2003). Although power over consumers may be necessary when life-saving treatment is required, it could be viewed as a hindrance at times, especially when working with individuals with mental illness and developing rapport. Rapport is based on the concepts of empathy, respect, and trust (O'Toole, 2008). When consumers possess limited power, this can cause a decreased sense of the aforementioned elements for those placed in a position to provide care (Carter, 2009).
Training nurses need opportunities to understand consumers in their care, and when the power shift is placed too highly toward the nursing end, this opportunity may not occur. Students' experiences in Recovery Camp allowed for the power paradigm to be diminished and thus spurred them to gain rich and robust personal information directly from consumers, which encouraged them to provide more meaningful and person-centered care. In addition, the alleviation of power could be viewed as a first step in the development of rapport. This finding is supported by Norfolk, Birdi, and Walsh (2007), who indicated that rapport is developed when all individuals involved (e.g., students, consumers) are provided the opportunity to gain a shared understanding and possess a sense of collaboration. In traditional power paradigms, the sense of shared understanding or collaboration is rarely evident. A plausible reason for the power shift could be attributed to the structure of Recovery Camp, in which everyone involved engaged in activities and tasks as participants.
Student Perceptions of Consumers was another theme within the dataset. This theme aligned strongly with the concept that attitude and preconceptions influence rapport (Ross, 2013). Each student was first provided opportunities to build a therapeutic relationship with a consumer. That, in turn, allowed for the development of a personal understanding of each consumer and not a symptom-first-and-person-second focus. In addition, students' preconceptions were skewed toward an ideal that individuals with mental illness would not be as capable in normal daily activities. Instead, the attitudes and preconceptions moved toward a focus that many individuals with mental illness are capable and have to learn to manage their diagnosis through the assistance of medication, exercise, nutrition, and other coping strategies.
Interaction and Communication was also an important theme and element of student participation in Recovery Camp. Communication can be viewed as a cornerstone of effective nursing and rapport building (Stephensen, Higgs, & Sugarman, 2001). Without being able to effectively communicate and interact with consumers, the level of information and proper care could be diminished. This finding is supported by the vast amount of research illustrating the importance of communication toward understanding consumer needs and care (Norfolk et al., 2007).
Finally, Resource Shift as a Result of Camp was another identifiable theme. Nurses are continuously developing their abilities and skills. As such, Recovery Camp provided a unique opportunity to illustrate that information is gained from books and colleagues, as well as directly from consumers. This theme could be deemed as one of the more unique elements of Recovery Camp. It would seem logical and important to view the consumer as a center of learning and information. Because students were not provided information about consumers, they engaged in conversations that facilitated a switch toward seeing the consumer, who has the most information about his/her illness and influence on all aspects of his/her life, as a valuable resource of knowledge.
Implications for Practice
Key elements of Recovery Camp supported the development of students' relationship-oriented skills that can facilitate person-centered care. Specifically, findings support that rapport was developed through Recovery Camp by providing an initial setting that lacked consumer information yet was supported by nursing and academic staff, and provided all participants with therapeutic, recreation-based activities. A key element that supported students' development of rapport was not providing information about consumers. Students were more focused on the consumer as a person, and not simply a set of symptoms. Alleviating the preconceptions and beliefs about consumer symptoms and diagnoses seemed to facilitate an enhanced understanding of each individual. As such, scaffolding of information is key to the development of nursing students whereby specific information (e.g., patient diagnosis) can direct students toward a certain way of thinking about a consumer. In addition, therapeutic, recreation-based activities were critical as they provided consumers and students with a means for developing personal recovery and engaging in activities as equals. It is a well-documented concept that therapeutic recreation-based activities are aligned with the development of personal recovery elements (Moxham, Liersch-Sumskis, et al., 2015). The students benefited by being participants in these activities as it aided in creating bonds with consumers and other students. The connection and bonds seemed to facilitate the development of rapport.
Provision of care is a cornerstone to any medical field. Within mental health, being able to connect to consumers can be influenced by creating and engaging in activities and/or tasks that require everyone to contribute to successfully complete or reach a goal. Entwining such elements within typical mental health clinical placements for undergraduate nursing students may better facilitate their relationship-oriented skills.
The current study is the first known to examine the influence of a therapeutic, recreation-based clinical experience on the learning and development of undergraduate nurses' relationship skills. Although the initial results demonstrated an enhanced level of rapport and mental health content knowledge, additional research and inquiry is needed. Future studies focused on experiences like Recovery Camp may need to delve deeper into understanding and identifying additional learning outcomes of placing students in these experiences using methodologies that include quantitative measures.
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Field Notes Taken According to Theme
|Initial Anxiety/Nervousness||“You could really see how both the students and [consumers] were a bit stand-offish in an attempt to get to know each other.”|
|“There were a number of times that I overheard students talking with each other about if it was okay to work with a consumer without consulting with either a staff member or nurse.”|
|Diffusion of Power||“As I watched everyone in different settings (e.g., activities, lunch, transition time), it would be very hard for someone on the outside to tell me who is the consumer and who is the student. There seems to be a balance between who takes the lead (student or consumer) and who follows in some of the activities.”|
|“During each activity, different people would take on a leadership position…. The interesting thing was that at different times it would be a consumer or a student who took charge…. I would guess that the focus on allowing each consumer's success dictated who would be the leader and who would be the follower.”|
|Student Perceptions of Consumers||“Breakfast, lunch, and dinner seemed to be a great time for people to share their feelings and stories. As I stepped back and observed the consumers and students at dinner, you could see a flurry of conversation about the days' activities and life in general.”|
|Interaction and Communication||“[During the cooperative game], the level of care and empathy in the voices of the students and the consumers was amazing. There was a sense of genuine care for the success of everyone.”|
|Resource Shift as a Result of Camp||“I watched one student during the evening session (5:00 p.m. to 9:00 p.m.). She was supporting a consumer who was displaying some distress (e.g., crying, withdrawn) and it was interesting to see how she gathered information from the consumer, would ask a nurse for some guidance and feedback to help, then go back to the consumer. This cycle repeated itself many times throughout the evening.”|