Exploring undergraduate nursing students’ experiences of their first clinical placement in an acute adult mental health inpatient service Mel Lienert-Brown June 2013 A thesis submitted for the degree of Master of Health Science at the University of Otago, Christchurch ABSTRACT Mental health nurses are vital to the mental health and addiction workforce. However, there are significant workforce challenges facing mental health nursing. With an aging workforce, increasing demand for mental health and addiction services and relatively few new graduates choosing mental health as a career the current shortage of mental health nurses is going to become more acute. One of the main impediments in recruitment to mental health nursing is that undergraduate nursing students do not see mental health nursing as a desirable career choice. Undergraduate nursing programmes provide opportunities to influence nursing students’ attitudes with positive clinical experiences in mental health being identified as having a significant impact on nursing students’ attitudes to people with mental illness and mental health nursing as a career. This small study seeks to develop a better understanding of the undergraduate nursing students’ experience of their clinical placement in mental health and identify the influences on student learning in an acute adult mental health service. This qualitative study was undertaken at one educational institution in New Zealand. A cohort of thirteen nursing students participated in this study. A process of thematic analysis was used to analyse students’ reflections on practice. Exploring the lived experiences of nursing students through their written reflections on practice offered important insights into the student experience of their first mental health clinical placement. From the analysis six themes emerged: The Unknown; Connecting; Relationships with staff; Questioning; Understanding; and Vulnerability. These themes allowed for a more meaningful understanding of the student experience of their clinical placement and the factors which influence this experience. This study provides educators and clinical staff with valuable information which can be used to develop innovative and positive clinical experiences for nursing students. With the ultimate goal being to develop caring, empathetic nurses who see mental health and addiction nursing as a dynamic and rewarding career option. i ACKNOWLEDGMENTS I would like to acknowledge and thank Dr Dave Carlyle, my primary academic supervisor for his guidance throughout this process. And also Professor Marie Crowe, my associate academic supervisor for the feedback she provided. I would like to thank Christchurch Polytechnic Institute of Technology for their generous support without which this research would not have been possible. I am also very grateful to all my colleagues in the School of Nursing who have shared their knowledge with me and have been so helpful at the various stages of this research. This research would not have been possible without the participants. I am immensely grateful to the nursing students who agreed to participate in this study. I would also like to acknowledge all of the students that I have had the privilege to work with over the past six years and from whom I have learnt so much. Finally, I would like to dedicate this to my wonderfully, supportive husband Tai, and to my children Amelia, Daniel and Anton – you will always be my three greatest achievements. Also, to Miss Mele for all the joy she brings to my life. A huge thank you to my sister Cindy for her assistance with proof-reading my thesis. And to my parents, Russell and Marion, for all your love and encouragement and for always believing that your ‘scatty’ was smart, she just needed to apply herself! ii TABLE OF CONTENTS ABSTRACT ............................................................................................................................................ I ACKNOWLEDGMENTS ................................................................................................................... II TABLE OF CONTENTS .................................................................................................................... III LIST OF TABLES ................................................................................................................................ V CHAPTER ONE: INTRODUCTION ................................................................................................ 1 1.1 RESEARCHER CONTEXT RELATED TO THE FORMULATION OF THE RESEARCH QUESTION ............................ 1 1.2 MENTAL HEALTH NURSING IN THE NEW ZEALAND CONTEXT ....................................................................... 2 1.3 THESIS STRUCTURE ........................................................................................................................................... 3 CHAPTER TWO: LITERATURE REVIEW ................................................................................... 6 2.1 INTRODUCTION .................................................................................................................................................. 6 2.2 LITERATURE SEARCHES .................................................................................................................................... 6 2.3 DEFINITION OF MENTAL HEALTH NURSING ..................................................................................................... 7 2.4 THE MENTAL HEALTH WORKFORCE IN NEW ZEALAND ................................................................................. 7 2.5 WORKFORCE CHALLENGES ............................................................................................................................... 9 2.6 UNDERGRADUATE NURSING STUDENTS’ ATTITUDES TO PEOPLE WITH MENTAL ILLNESS AND MENTAL HEALTH NURSING .............................................................................................................................................. 9 2.7 THE ROLE OF EDUCATION IN INFLUENCING NURSING STUDENTS’ ATTITUDES ........................................... 10 2.8 THE CLINICAL EXPERIENCE IN MENTAL HEALTH ......................................................................................... 12 2.9 EXPLORING THE LIVED EXPERIENCE OF THE CLINICAL PLACEMENT ........................................................... 17 2.10 SUMMARY ........................................................................................................................................................ 21 CHAPTER THREE: METHODOLOGY .........................................................................................23 3.1 RESEARCH QUESTIONS .................................................................................................................................... 23 3.2 SAMPLE ............................................................................................................................................................ 23 3.3 CONTEXT OF CLINICAL COURSE ..................................................................................................................... 23 3.4 DATA ................................................................................................................................................................ 24 3.5 RECRUITMENT .................................................................................................................................................. 25 3.6 ETHICAL CONSIDERATIONS ............................................................................................................................. 25 3.7 STORAGE AND DISPOSAL OF DATA ................................................................................................................. 26 3.8 METHODOLOGY ............................................................................................................................................... 26 3.9 DATA ANALYSIS .............................................................................................................................................. 27 3.9.1 Boyatiz’s Thematic Analysis Framework ................................................................................. 29 3.9.1.1 Stage 1: Deciding on sampling and design issues ....................................................................................... 29 3.9.1.2 Stage 2: Developing Themes and a Code ................................................................................................... 30 3.9.1.3 Stage 3: Validating and using the code ....................................................................................................... 32 3.10 SUMMARY ........................................................................................................................................................ 33 iii CHAPTER FOUR: RESULTS ...........................................................................................................34 4.1 THE UNKNOWN ................................................................................................................................................ 34 4.2 CONNECTING .................................................................................................................................................... 38 4.3 RELATIONSHIPS WITH STAFF ........................................................................................................................... 43 4.4 QUESTIONING ................................................................................................................................................... 46 4.5 UNDERSTANDING ............................................................................................................................................. 51 4.6 VULNERABILITY .............................................................................................................................................. 57 4.7 SUMMARY ........................................................................................................................................................ 61 CHAPTER FIVE: DISCUSSION .......................................................................................................63 5.1 SUMMARY ........................................................................................................................................................ 78 CHAPTER SIX: CONCLUSION .......................................................................................................81 6.1 LIMITATIONS .................................................................................................................................................... 83 6.2 STRENGTHS ...................................................................................................................................................... 83 6.3 RECOMMENDATIONS ....................................................................................................................................... 83 6.3.1 Preparation Prior to Clinical ................................................................................................... 83 6.3.2 Orientation to Clinical Environment ........................................................................................ 84 6.3.3 Structured Learning Activities During Clinical Placement ..................................................... 84 6.3.4 Education and Support for Clinical Staff Working with Students ........................................... 85 6.3.5 Education and Support for Academic Staff Working with Students ........................................ 85 6.4 IMPLICATIONS FOR FURTHER RESEARCH ....................................................................................................... 86 6.5 SUMMARY ........................................................................................................................................................ 87 REFERENCES .....................................................................................................................................88 APPENDICES ......................................................................................................................................99 APPENDIX 1: ETHICS APPROVAL FROM CPIT .................................................................................................... 100 APPENDIX 2: ETHICS APPROVAL FROM UNIVERSITY OF OTAGO, DEPARTMENT OF PSYCHOLOGICAL MEDICINE .......................................................................................................................... 102 APPENDIX 3: BOARD OF STUDIES APPROVAL .................................................................................................... 106 APPENDIX 4: PARTICIPANT INFORMATION SHEET ............................................................................................. 109 APPENDIX 5: CONSENT FORM ............................................................................................................................. 111 APPENDIX 6: POSTER ADVERTISING RESEARCH ................................................................................................ 113 APPENDIX 7: PORTFOLIO LEARNING ACTIVITY ................................................................................................. 115 APPENDIX 8: REFLECTION GUIDE....................................................................................................................... 117 iv LIST OF TABLES Table 1:   Percentage of Graduates Entering Mental Health Nursing ...................................... 8  Table 2:  Categories and Themes .......................................................................................... 31  v CHAPTER ONE: INTRODUCTION 1.1 Researcher Context Related to the Formulation of The Research Question As a mental health nurse working in an acute adult inpatient ward I often worked with nursing students during their clinical placement. While most students appeared to embrace this experience, there were a number of students for whom this seemed to be a confusing and scary experience which they endured rather than enjoyed. It was a topic of much debate amongst the nursing team as to whether our ward was a suitable clinical placement for nursing students, with many nurses believing that the acute environment was not a safe environment for undergraduate nursing students. Five years ago I moved into nursing education and now work fulltime teaching in the Bachelor of Nursing programme at our local education provider. I continue to work with nursing students in the acute mental health environment but this time in a clinical lecturer role. As a clinical lecturer I spend two and half hours per week with students in clinical and therefore only get a small snapshot of what their experience is. Most of this is relayed through the conversations we have and in the reflections they write on practice. Student feedback suggests that the acute mental health environment is a rich learning environment for nursing students and most students report that they enjoyed their mental health placement but very few of them chose to return to mental health nursing on graduation. This led me to wonder how accurate this student feedback was and question how much I actually knew about the nursing students’ clinical experience. I would like to have a better understanding of the student experience during their mental health placement. This understanding will enable me to develop my clinical lecturer role to ensure that I am working with students in a way that best meets their needs and supports their learning. This knowledge can also be used to work with clinical staff to develop and improve the clinical experience with the desired outcome being to provide positive clinical placements in which nursing students are supported to grow in confidence and competence when working 1 with people with mental illness, and as a result of this positive clinical experience see mental health nursing as a dynamic and rewarding career choice. 1.2 Mental Health Nursing in the New Zealand Context Mental health disorders are common in all regions of the world, with 14% of the global burden of disease being attributed to these disorders (World Health Organisation, 2013). Mental health is a priority health area for the New Zealand government with 47% of New Zealanders experiencing a mental illness and/or an addiction at some time in their lives, and one in five people affected in any given year (Ministry of Health, 2013). With increasing demand for mental health and addiction services comes increasing pressure on the mental health workforce. Over the past ten years the Ministry of Health has invested significantly in workforce development with the vision being to create a workforce that is responsive to the needs of service users and able to contribute positively to people’s recovery journeys (Mental Health Commission, 1998). In the second Mental Health and Addiction plan, Te Tahuhu (Ministry of Health, 2005) one of the ten leading challenges identified was workforce and creating a culture for recovery. This challenge emphasises the importance of a knowledgeable, skilled, competent, recovery-focused workforce that can deliver the right mix of services for the changing demographics of the New Zealand population (p. 12). Mental health nurses are vital to the mental health workforce as they are the largest regulated members of the workforce (Ministry of Health, 2011) but there are significant workforce challenges facing the mental health and addiction sector in New Zealand as there has been and is still currently a shortage of qualified mental health nurses. With increasing demand for mental health and addiction services, an aging mental health nursing workforce and relatively few new graduate nurses choosing mental health as a career this shortage is going to become more acute. Therefore the recruitment of nurses to mental health is a pressing concern and must be addressed in order to create the desired knowledgeable, skilled, competent and recovery-focused workforce which is responsive to service user’s needs. There are a range of specific issues impacting on recruitment and retention of the mental health nursing workforce including: underfunding in mental health services, workload, stress, the impact of role changes and undergraduate education (Roche & Duffield, 2007). One of the main impediments identified to recruitment is the fact that mental health nursing is not seen as 2 a desirable career choice for undergraduate nursing students (Hoekstra, van Meijel, & van der Hooft-Leemans, 2009, p. 4; Kloster, Hoie, & Skar, 2007, p. 158; McCann, Clark, & Lu, p. 34; Rushworth & Happell, 2000, p. 132). There are a number of explanations for this including fear of working with people with mental illness, a perceived inability to cope with this clientele, a belief that the working environment would be unpleasant, stressful and frustrating, insufficient knowledge of this specialist area and the belief that they were personally unsuited to this area of practice. (Happell, 1999, p. 503; Hoekstra et al., 2009, p. 6) Undergraduate nursing programmes provide opportunities to produce more positive attitudes in nursing students towards people with mental illness and mental health nursing. There is some evidence that theoretical preparation is an important factor in influencing the attitudes of undergraduate nurses towards working with people with mental illness and mental health nursing (Happell, 2009b, p. 44; Happell, Robins, & Gough, 2008, p. 445; Rushworth & Happell, 1998, p. 324). However, it is clinical experience in mental health (Happell, 2009b) which has consistently been acknowledged in literature as having a significant impact on nursing students’ attitudes towards working with people with mental illness and mental health nursing as a career (Happell, 2000, p. 47; 2001, p. 513; Mullen & Murray, 2002, p. 64; Rushworth & Happell, 1998, p. 324). Therefore it is important to understand what constitutes a quality clinical placement in mental health. One way to achieve this is through exploring the student’s experiences whilst on these placements. The aim of this study is to explore the undergraduate nursing student’s experience of their first clinical placement in an acute adult mental health inpatient service and identify the influences on student learning in an acute adult mental health service. The knowledge generated from this study can then be used to develop and improve the clinical experience with the desired outcome being to create positive clinical experiences which not only challenge the stigmatising and negative attitudes held by nursing students towards people with mental illness and mental health nursing but also to present mental health nursing as a dynamic and rewarding career option. 1.3 Thesis Structure Chapter 1 explains the background context to the study from the researcher’s perspective. It begins by situating mental health nursing within the mental health and addiction sector and 3 identifies some of the workforce challenges. Some specific issues impacting on recruitment in mental health nursing are outlined and the role of education and specifically the clinical experience in addressing these is identified. Chapter 2 describes the literature review process and explains the search strategy. It begins by defining mental health nursing and describing the current mental health nursing workforce. It then expands on some workface challenges facing mental health nursing in New Zealand and globally. Next the link between nursing students’ attitudes towards people with mental illness and mental health nursing and recruitment to mental health nursing is made. Literature identifying the role of education in influencing nursing students’ attitudes is reviewed. This is followed by a thorough review of literature pertaining to undergraduate nursing students’ clinical experiences in mental health settings. Finally it describes how reflection on practice has enabled educators to examine more closely the experience of the student during their clinical placement. Chapter 3 offers an overview of the research methodology used in the study. A description of the participants and recruitment process is provided. Ethical considerations are explained, including the approval process, how potential risk to participants was managed and confidentiality. It then briefly explains qualitative research and its applicability to this study. The analytical framework ‘thematic analysis’ is defined and its steps described. Finally the application of this framework to this study is explained. Chapter 4 outlines the results of the data analysis. The six themes uncovered during data analysis are identified. Each of these themes is defined, described and illustrated through the use of excerpts from the data. The first theme is ‘The Unknown’. This theme is characterised by the uncertainty and anxiety that students expressed during their first two weeks of their clinical placement. ‘Connecting’ was the second theme to emerge from the data. Connecting relates to the desire nursing students’ had to connect with patients and the data demonstrates how nursing students try to establish these connections. The third theme is ‘Relationships with Staff’. The relationships described by students were both positive and negative and are shown to have a significant impact the students’ perception of the clinical environment. In the fourth theme ‘Questioning’, students begin to uncover and question their own attitudes to mental illness as well as questioning some of the nursing practice they had observed. Following on from this theme is the fifth theme ‘Understanding’. This theme is based on the students’ attempts to understand mental illness and its impact on the people they are working 4