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Strategies for Improving Nursing Students' Mental Health Clinical Rotation

Article in Journal of Christian Nursing · July 2016

DOI: 10.1097/CNJ.0000000000000298

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Strategies for Improving Nursing Students’

Mental Health Clinical Rotation
ABSTRACT: Mental illness is a huge problem many people face in the Christian schools, journaling can help
U.S. and around the world. The American Psychiatric Nurses Association students connect their nursing care
indicates there is a shortage of nurses in every level and role in psychiatric- with Christian faith.
mental health nursing. Raising up a generation of nurses who want to work MENTAL HEALTH EDUCATION
with the mentally ill is a challenge for nurse educators. The use of role playing Patients who suffer with mental
and simulation in the learning lab prior to entering the clinical setting and illness are at increased risk for poor
reflective journaling in the clinical rotation can improve undergraduate nursing health outcomes, have less access to
students’ mental health clinical experience. healthcare, and suffer with multiple
comorbidities, all of which create
KEY WORDS: mental health, nursing education, psychiatric nursing, significant nursing practice issues
reflective journaling, role playing (American Nurses Association, 2016).
The current lack of mental health

M
ost of us know
someone, maybe even
our own family
members, who have
suffered or continue to suffer with
mental illness. In 2014, there were an
estimated 9.8 million adults in the U.S.
with a serious mental illness, represent-
ing 4.2% of all adults (National
Institute of Mental Health [NIMH],
2014). Furthermore, over 20% of
children (one in five) have or have had
a seriously debilitating mental illness
(NIMH, 2016). The majority of those
with mental health conditions also
have comorbid medical problems
(68%), whereas about a third (29%) of
people with medical problems have
comorbid mental health conditions.
This presence of a comorbid mental
condition significantly raises the cost
of treating medical problems (American
Maureen Kroning, EdD, RN, is
a nursing supervisor at Good
Samaritan Hospital, Suffern, New
York, and an ­associate professor at
Nyack College of Nursing. Her
greatest reward is ­teaching future
generations of nurses.
The author declares no conflict of interest.
Accepted by peer-review 5/27/2015.
DOI:10.1097/CNJ.0000000000000298
education nursing students receive is
Hospital Association, 2012). Treat-
ment for mental illness is a significant
need in healthcare in the U.S. and
around the world (World Health A positive mental health
Organization, 2016). Raising up a
generation of nurses who want to clinical rotation results in
work in behavioral health with the
mentally ill is a challenge for nurse improvement of nursing
educators.
A positive mental health clinical student attitude, better
rotation results in improvement of
nursing student attitude, better preparedness when providing
preparedness when providing care for
individuals with mental illness, and
care for individuals with
increased inclination toward mental mental illness, and increased
health nursing as an option after gradu-
ation (Happell, 2008). Nursing students inclination toward mental
need to be provided with the knowl-
edge, skills, and support necessary to health nursing as an option
provide care to patients, families, and
communities affected by mental illness. after graduation.
One method that can help create a
positive experience and improve
knowledge and skills is the use of
reflective journaling with nursing a key concern. According to the
students during their mental health American Psychiatric Nurses Associa-
clinical rotation. Journaling provides a tion (APNA, 2015), undergraduate
valuable tool to assess students’ clinical nursing programs provide a rotation in
experience, learning needs, reflective psychiatric-mental health nursing,
insight, while learning to care for introducing students to the mental
patients with mental illness. For health specialty and helping students

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decide if mental health nursing is a
specialty they wish to pursue. However,
this is insufficient for the numbers of
patients suffering with mental illness.
Furthermore, APNA recognizes there
is a shortage of nurses in every level
and role in psychiatric-mental health
nursing. There is concern that nursing
programs are not adequately addressing
the need for nurses to receive mental
health education (Anonymous, 2012).
In the bachelor’s degree nursing
program in which I teach, students
receive 7 weeks of mental health
education, including both classroom
and clinical rotation.
According to Curtis (2007), the
reason new graduates do not enter
mental health nursing is that they feel
ill-prepared, have perceived prejudices
and apprehension toward mental illness,
lack clinical placement support, and
have less than clinical experiences. A
positive clinical experience is critical to
nursing students feeling prepared to
care for patients with mental illness.
Henderson, Happell, and Martin
(2007) found a positive clinical
experience was the most influential
factor in nursing student’s knowledge,
skill, and attitude in caring for patients
with mental illness. Engaging nursing
students in clinical to see patient
experiences within health, illness, and
the healthcare system can help them
learn about the “multiplicity of views
on experiences” and assist students to
recognize their patient as an individual
and the need for patient-centered care
(Shattell, 2007, p. XX)AQ1. According
to Dunlap (2006, p. 20), “many
professions are increasingly emphasiz-
ing the role of reflection, encouraging
educators to look for appropriate ways
to help students engage in reflective
practice during their professional
preparation.” Journaling can help
engage students in reflecting on their
clinical experiences, help nurse
educators create rewarding clinical
rotations, and help change student’s
perceived prejudices and apprehensions
about mental health.
E24 JCN Copyright ©2016 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.
JCN0916_Online Only_00014_Deepak.indd 24
JOURNALING IN Kuo, Turton, Cheng, and Lee-Hsieh
NURSING EDUCATION (2011) conducted a descriptive
Journaling is a powerful learning qualitative study of 880 senior nursing
tool that enhances critical thinking, students and 90 clinical instructors.
improves nursing skills, improves After 1 year, 16 nursing students and 7
student attitudes, and prepares students clinical instructors participated in focus
for their professional nursing role. group interviews about reflective
Schuessler, Wilder, and Byrd (2012) journaling. Six common themes
found journaling allowed students to emerging from the interviews were
reflect on their experience and over that reflective journaling:
time, aided in the students’ develop- • Guides caring behavior toward
ment of cultural humility, a skill that patients,
cannot solely be learned in a class- • Provides students ability to reflect
room. Reflective strategies have many on caring abilities,
proven advantages, such as being • Develops students’ self-confidence,
utilized in a variety of settings, assisting • Increases interaction between
students to put reflective skills into student and instructor,
practice in a controlled, safe environ- • Enhances students’ self-­
ment, and are known to improve both development,
• Improves writing skills.
Recently, I took 18 third-year
nursing students to a U.S. Department
of Veterans Affairs hospital for their
Journaling is a powerful learning mental health clinical experience and
utilized reflective journaling as an
tool that enhances critical educational tool. Students were
required to email or hand in journal
thinking, improves nursing entries within 24 hours after their
skills, improves student attitudes, clinical experience. At the start of this
clinical rotation, I requested students’
and prepares students for their permission to keep their journal
entries, informing students that their
professional nursing role. journal entries would be assessed for
common themes and learning oppor-
tunities. I also informed students
that I wanted to publish my findings,
including students’ comments, but that
nursing satisfaction and patient care student names would remain anony-
(Cooke & Matarasso, 2005). Epp mous. Students were told that they
(2008) conducted a literature review of would not be penalized if they did not
150 abstracts focused on reflective wish to include their journal entries; all
journaling in undergraduate nursing students granted permission. The
education and found the use of emailed journals were kept secured in a
journaling as an educational tool password-protected drop box on the
resulted in student learning. Lasater course site and the paper journals were
and Nielsen (2009) found reflective, locked in my office.
guided journaling provided insight Students were provided with a
into what students were thinking journal rubric to guide their reflections
during their clinical experience. (Table 1). The rubric included three
Providing guided questions to the categories to assess student growth:
journal assignment allowed students to personal, professional, and spiritual.
focus on the responses of each Each category included specific
question (Dunlap, 2006). examples for reflection. Personal
27/04/16 1:34 PM
 Table 1: Journal Rubric Used to Guide Student Reflections*
Student Name ____________________________________ Date______________ Grade______________
Please provide examples of how you achieved each category during your clinical experience.

PERSONAL GROWTH Meets Nursing 3/3 √ = Outstanding 2/3 √ = Satisfactory < 2 √ = Unsatisfactory
Objective:
1. Describe your greatest 5, 6
challenge
2. Identify and discuss any 3, 4
Meets all 3 Meets all 2 Meets < 2
bioethical concerns
Clinical ­Experience Clinical ­Experience Clinical Experience
& relationship between
criteria. criteria. criteria.
the environment and health.
3. Describe your greatest
accomplishment
PROFESSIONAL GROWTH Meets 4/4 √ = Outstanding 3/4 √ = Satisfactory <3 √ = Unsatisfactory
Nursing Objective:
1. Demonstrated technical skills 5
2. Demonstrate planning and 2, 3, 7
intervention of cultural, holistic
competent care for your patient
while considering the patient’s
perception of health and illness Meets all 4 Meets 3 Meets < 3
Self Reflection Self Reflection Self
3. Demonstrated interpersonal 1, 5 criteria. criteria. Reflection criteria.
communication skills with inter-
disciplinary healthcare team
4. Demonstrated interpersonal 5
communication skills with
classmates and instructor
SPIRITUAL GROWTH Meets 3/3 √ = Outstanding 2/3 √ = Satisfactory < 2 √ = Unsatisfactory
Nursing Objective:
1. Provides a Bible Scripture 4, 5, 7
reference to clinical experience

2. Showed initiative to pray 1, 2, 3 Meets all 2

Meets all 3 Professional Meets < 2 Professional
Professional Growth
3. Demonstrates: willingness to 1, 2, 4,6 Growth criteria. Growth criteria.
criteria.
help others, caring, advocates,
and cares for culturally diverse
patients

*Grading: Please add up the total points in each category. The maximum total score that can be achieved is a 10.

growth included the student’s greatest
challenges, their greatest accomplish-
ments, identifying and discussing
bioethical concerns, and the relation-
ship between the environment and
health. Professional growth included
technical skill, planning, intervention,
culturally and holistic care, interper-
sonnel communication with interdisci-
plinary healthcare team members, as
well as classmates and clinical instruc-
tor. Spiritual growth included applying
Scripture references to the clinical
experience, showing initiative to
demonstrate care, and advocacy for
others and culturally diverse patients.
Each area aligns with the nursing
program’s curriculum objectives.
My hope was that this assignment
would provide students with insight
into their clinical experience, their
accomplishments, their challenges, and
the connection to helping others as
Christians and Registered Nurses who
chose a profession of helping others.
Students were provided with feedback
about their journals; often students
shared their journal entries with
classmates. Surprisingly, not only did
students verbalize journaling was a
positive experience, reading each
journal provided insight through the
students’ eyes of how I as an educator
can better assist with their learning
needs.
THROUGH THE STUDENTS’ EYES
Prior to the start of the mental
health clinical rotation, students
verbalized fear, apprehension, and
anxiety related to caring for patients
with mental illness. Students’ concerns

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made it essential to assess the journals
for answers regarding the source of
these issues. Journaling proved an
effective tool that provided a glimpse,
through the students’ eyes, of what they
experienced during their clinical
rotation.
The journal entries were designed
to guide students to use reflective
insight to capture the personal,
professional, and spiritual growth
encountered during students’ clinical
experiences. The personal growth
category, which included perceived
challenges and accomplishments,
provided insight to common themes
during clinical rotation. Students often
included items of all three growth
areas. Students commonly wrote about
challenges they experienced in their
earlier clinical sessions, whereas their
sense of accomplishments occurred
toward the end of the clinical rotation.
This may indicate that with time and
practice, improvement with patient
interaction occurred. Table 2 shows
Table 2. Student Challenges and Accomplishments
Reported in Reflective Journals
Student Challenges
Feeling anxious to interact with patients
Not knowing what to expect in clinical
Knowing what to do with aggressive/
threatening patients
Not agreeing with staff’s interaction with
patients
Not sharing Christian faith with patients
and staff
Insecure helping patients
Fearful interacting with patients
Not judging or stereotyping patients
E26 JCN Copyright ©2016 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.
JCN0916_Online Only_00014_Deepak.indd 26
both student challenges and accom-
plishments, noting that student
accomplishments were discussed more
often in the journals.
Many of the challenges expressed in
the journal entries were opportunities
for the students to learn. After the first
mental health clinical rotation one
student wrote, “Getting through my
first clinical day with a positive
experience made me less anxious about
what to expect the rest of the semes-
ter.” Often, students read their journal
to the clinical group and we reflected
on the particular clinical experience.
For instance, students felt it was a
challenge when they did not agree
with how a staff member interacted
with patients. I asked students to
provide a specific interaction; a few
students mentioned a particular staff–
patient interaction that included the
patient, the psychiatrist, the nurse, the
social worker, a medical student, and
the three nursing students. The students
recalled that the patient became upset
Student Accomplishments
Improved patient interaction
Confidence recognizing mental health
disorders
Participating in group sessions
Courage to ask questions
Communicate effectively with staff
Not stereotyping or judging patients
Working through personnel issues
Believing in prayer
Having knowledge to help mental
health patients
Motivated to be a nurse
Making a positive difference
and angry about the questions being
asked of him. Students felt the ques-
tions were confrontational and did not
include therapeutic communication
techniques. Journaling allowed us to
explore the challenging situation and
provided an opportunity to identify
alternative therapeutic responses that
could have been provided.
Perhaps the most unexpected
challenge students identified was that
they felt they could not share their
Christian faith with patients and staff.
When I asked students to provide more
detail, they voiced concern that the
healthcare facility was secular, many
patients were not Christians, and
believed staff would probably not allow
faith sharing. As a nurse educator, and
as a Christian, this area required careful
analysis and discussion with students to
explore appropriate spiritual care.
REFLECTIVE INSIGHT
When students wrote about their
greatest challenges/accomplishments,
there was evidence of using reflective
insight during their clinical rotation.
For example, when one student talked
about a perceived challenge, he also
reflected a deep sense of wanting to
help his patient, but felt insecure to do
so. The student wrote, “The greatest
challenge for me today, was looking at
a patient’s art work and being able to
feel the patient’s pain and sorrow, but
not knowing what to say.” Another
student wrote, “A challenge for me was
hearing the confession of a young
patient talking about hurting himself.
This was sad for me because I felt like I
could have made a difference in his life
if I was confident enough to give him
words of encouragement.”
Student accomplishments also
provided evidence of reflective insight.
Many students expressed an increase in
confidence. A student wrote his
greatest accomplishment was “having
the courage to ask questions and
communicating effectively with staff ”
while “learning not to stereotype or
judge patients.” Nursing students often
27/04/16 1:34 PM
 verbalize preconceived judgments and
prejudices prior to entering their
mental health clinical rotation. There-
fore, preparing students prior to
entering the clinical setting is vital.
Journal entries provided reflective
insight to how students saw the
struggles of their patients and were able
to relate these struggles to their own
lives. “The greatest accomplishment for
me was going back to a place where I
have come from, and being able to
view it in the new light of nursing.” I
asked this student to expand. “Alcohol
addiction can become a part of a
person’s life no matter their race,
ethnicity, religion, profession, or age,
and it was a part of mine. Working
through addiction into freedom was
very difficult for me, and it was
challenging to understand why others
coming through addiction would turn
back.” The following statements made
by this student illustrate that learning
that took place in the clinical setting:
During my experience at the
Veteran’s Affairs, I began to under-
stand that each person takes a dif-
ferent path and some may relapse
one time, some 10 times, some will
never go back, while many addicts
will never find complete freedom.
The truth is, as a nurse and a person
helping other’s work through difficult
life issues, we support the person and
every good choice made. We encour-
age and applaud every effort toward
healthy living. We stand beside the
person, even when he falls. This, to
me, is a picture of beauty, to look
beyond the action and the conse-
quences and find a person within.
Many student journals included
insight into their spiritual belief in
prayer and God. A student wrote, “My
greatest accomplishment is in knowing
that our prayers are being answered
every day at the end of clinical. We pray
to be a blessing to the clients we
encounter, and God has shown us the
smiles and the gratitude on the faces of
Copyright ©2016 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.
JCN0916_Online Only_00014_Deepak.indd 27
each veteran we speak to.” The student The authors recommended that
concluded, “I am pleased that God can spirituality and spiritual care be
use me and my clinical group to express included in nursing curricula in order
his love to others.” Another student to improve quality nursing care.
wrote, “Having a patient tell me that he Including spiritual growth in the
did not feel depressed that day because journal allowed students to reflect on
their spiritual growth and helped them
to transition from seeing nursing as
more than a profession, viewing
nursing as God’s plan for them, and
Not only did students verbalize how being a Christian is essential to be
the Christian nurse they strive to
journaling was a positive become one day. Common themes for
experience, reading each spiritual growth were less evident in
student journal entries because their
journal provided insight spiritual growth appeared to be
intertwined in reflecting on both
through the students’ eyes of accomplishments and challenges.
However, praying and discussing
how I as an educator can better spirituality in both pre- and postclini-
cal conferences were essential to
assist with their learning needs. promote students’ spiritual growth.
Through reading student journals,
prayer proved to be an important role
played in the clinical setting by helping
of seeing all of us there to talk and guide the students throughout their
know that someone cares was an answer clinical day. Students wrote how they
to our prayers.” One student wrote, felt their prayers were answered by the
“The more I gain from my clinical patient interaction during the clinical
experience, the more I am motivated to day. On one particular clinical day, two
become a nurse and the more confident students and I sat in to observe while
I become in community with my patients were called in to meet with
patients.” A student commented, their psychiatrist, nurse, and case
“Mental health is something that is worker. One patient was asked how he
frequently overlooked in the healthcare was doing with his depression. He
field. However, having that knowledge answered, “Today, seeing the students
means there is something we can do faces and having them talk to me,
about it, and knowing that, was an makes me feel that someone truly cares
accomplishment for me.” As a Christian about me. Because of that, my depres-
nurse educator, helping students connect sion is much better.” This was inter-
their faith to the care provided to preted as a testament to students and to
patients with mental illness was essential me that God was listening to our
in meeting my goals as a teacher. prayers to make a positive difference in
the patients’ lives. A student wrote this
CONNECTION WITH FAITH in his last clinical journal entry,
Wu, Liao, and Yeh (2012) conducted
a cross-sectional descriptive study of As a look back over these past
239 senior nursing students at 22 seven weeks of clinical, I realize
nursing schools and found that students I have learned so much beyond
who had taken courses on spirituality classrooms and books, and into a
and were interested in nursing as a world of flesh and blood, and most
career, had better spirituality knowl- importantly into a world of hearts
edge and attitude toward spiritual care. and souls.
JCN E27
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A vital part of the student journal
was choosing a Scripture reading that
reflected the day’s clinical experience.
The most cited Scripture was,
You are the light of the world. A
city set on a hill cannot be hidden.
Nor do people light a lamp and put
it under a basket, but on a stand,
and it gives light to all in the house.
In the same way, let your light
shine before others, so that they may
see your good works and give glory
to your Father who is in heaven.
(Matthew 5:14-16, ESV)
When I asked the students why they
chose this Scripture, they said it was
because it allowed them to feel as
though they were being the light
shining for their patients, and thus
praising God in heaven.
NURSE EDUCATORS’ ROLE
Nurse educators need to prepare
students for the mental health clinical
rotation. There are interventions that
Table 3. Student Learning Needs and Educator
Interventions Addressed in Learning Lab Prior to
Clinical Setting
Student Learning Needs
Feeling anxious, insecure, fearful
interacting and helping patients
Not knowing what to expect in clinical
Journaling allowed us to
explore the challenging
situation and provided an
opportunity to identify
alternative therapeutic
responses that could have been
provided.
can assist both educator and student to
create a rewarding clinical experience.
Meeting in the nursing lab to practice,
and even simulate, mental health
scenarios students face in clinical can
create a positive experience, help
decrease clinical anxieties, and ensure a
productive learning environment
during their clinical rotation. In the
nursing lab, fears and anxieties of
Educator Intervention
• Open discussions
• Role play similar scenarios
• Practice therapeutic communication
• Instructor support at clinical site
• Open discussions
• Role play similar scenarios
• Instructor support at clinical site
students can be discussed openly, and
educators can reassure students that
they will be present in the actual
clinical setting for any guidance and
support students may need.
The use of role playing is an
effective intervention that can help
students practice therapeutic commu-
nication skills and receive constructive
feedback from the educator. With role
playing, students are presented with
patient scenarios they will likely
encounter in the clinical setting, while
being able to practice therapeutic
communication and how to respond if
a patient is aggressive or threatening or
a staff member does not respond in a
therapeutic manner to a patient.
Students have opportunity to practice
interview questions.
It was essential that students
understood that when conducting a
patient interview, asking patients about
their spiritual and religious beliefs and
practices is critical to developing a
holistic plan of care. Nurses need to be
able to assess if their patient has
spiritual needs, wants to discuss their
spirituality or faith, and when, and if
the conversation warrants, the nurse
should engage in spiritual conversa-
tions. It was essential to teach students
that feeling confident with patient
interactions takes learning not only
about diseases and mental illnesses, but
time and practice. Table 3 lists student
learning needs and educator interven-
tions that were addressed in the
simulation lab prior to the mental
health clinical rotation.

Knowing what to do with aggressive/
threatening patients
Not agreeing with staff’s interaction
with patients
Not sharing Christian faith with patients
and staff
• Open discussions
CONCLUSION
I learn just as much from student
• Role play similar scenarios
• Instructor support at clinical site journaling as the students do. Requir-
ing students to complete a journal
• Open discussions
assessing their personal, professional,
• Role play similar scenarios
• Instructor support at clinical site and spiritual growth provides a valuable
• Speak with instructor if situation occurs tool to use as a nurse educator to
evaluate the student’s clinical experi-
•A
 sking patient about faith is part of
ence, student’s learning needs, student’s
standard history
•S
 howing compassionate empathetic care reflective insight, and the student’s
demonstrates Christian values ability to connect Christian faith while
learning how to care for patients with

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JCN0916_Online Only_00014_Deepak.indd 28 27/04/16 1:34 PM

 mental illness. Reflecting on personal,
professional, and spiritual growth
allowed students to gain confidence in
caring for patients in the clinical
setting. Journaling was more than just
an assignment; it was a valuable
learning tool. Reading each student
journal was a rewarding experience.
Providing students with rewarding
clinical experiences, positive reinforce-
ment, and support during their mental
health clinical rotations can help
decrease fears and anxieties, and help
students become interested and
motivated to practice in the mental
health setting. We began each clinical
day asking God for guidance and
strength. My prayer was that as a
Christian nurse educator, I would learn
from my students and they would learn
from me, and in the end we would
make a positive difference in the lives
of the patients we encountered.
Reading each journal entry and
witnessing student growth and their
reliance on prayer to strengthen and
guide them as they cared for patients
who suffer with mental illness was a
rewarding experience.
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behavioral health into the care continuum: Opportunities
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